Thoughts on sub division, coverage and density

[the B spot]

Well, I guess I would like to start writing out some of the ideas or thoughts I have been putting together over the last few months.

 

I would ideally like to take one aspect of hair transplantation and examine it, write out what I think or have discussed with others, etc... and just go from there.

 

Recently, we have been discussing sub follicular division---- we still have no real answer or agreement but setting that aside, I want to discuss some theories I have--- see what you guys think.

 

We are all well aware that hair grows in natural groupings of 1,2, 3, 4, and 4-6 hairs.

Most of us are aware that according to published studies, the normal breakdown of follicular units (in the donor region) is: 15% 1 hair grafts, 51% 2 hair grafts, 29% 3 hair grafts and 5-6% 4 hair grafts (4-6 hair grafts).

 

So using this info (I am aware that patients differ, but for the sake of argument), lets examine a 4000 grafts session using normal published graft distribution.

The breakdown is:

600---- 1 hair grafts

2040--- 2 hair grafts

1160--- 3 hair grafts

200---- 4 hair graft

 

When we look at this we have 2,640 fu's that represent the most refined grafts already, pure and unadulterated in their natural state.

 

What remains are 1360 multi- hair grafts and it is among these grafts that any sub-follicular division would have to take place. (I am not talking about splitting fine 2 hair grafts for hair line work)

 

One of the first issues that immediately appears is the follicular groupings themselves often twist together or grow so closely that they are unable to be split. Of course, one could posit that transecting 1 hair to get 2 or 3 refined 1 hair grafts (out of a 3-5 hair graft) is acceptable, but I would like to assume that this practice is too egregious to consider.

 

When we look closely at these 1360 grafts---- what type of parameter can be set for just how far they can be sub-divided?

 

I think it would be categorically impossible to sub-divide all of these grafts, unless of course the practice of splitting involves risking 1 fu to sub-divide it into 2-3 grafts.

 

I am going to place this at 50%--- no hard data, just theory, gut and willingness to offer a starting point.

 

1360 divided by 2 = 680

Before we sub-divide any grafts we have 3,320 naturally occurring follicular units and 680 3-6 hair grafts that we are preparing to sub-divide.

 

If the 680 grafts are split in HALF(1360)--- the graft total moves to 4,680 grafts

If the 680 grafts are split into 3rds(2060)--- the graft total moves to 5,360 grafts

 

Obviously, the corresponding hair counts will be lower, probably in the 1.6-1.7 hair to graft range, as opposed to the normal 2.2-2.3 hairs per graft.

A greater preponderance of 1 hair grafts should exist as well.

 

Even if my 50% of the "multi-grafts" is off 10-15% either way, it is easy to see how graft totals can be inflated past the yield of naturally occurring follicular units.

 

We see how 4000 grafts turns into 4,680 or 5360 grafts by sub-dividing a relatively small portion of the multi-haired grafts yielded.

 

My next question is---- Is this an altogether bad practice?

 

I think all of us will agree that tightly packing 55-65 1 hair grafts into the first 1-1.5cm of the hairline would look amazingly soft and natural and still provide the density most of us are looking for.

 

What about the frontal core and mid-scalp areas?

What about the lateral humps?

What about the crown?

 

What IF I went to my Doc and said I have 90cm of crown to cover, but I only have 2000 naturally occurring follicular units. (This would cover the crown at about 22 fu cm/2)

However, I asked for them to be sub-divided into 2600 grafts (This would cover the crown at about 29 fu cm/2).

 

The same hair is being moved, but a theory that transplanting 1 and 2 hair grafts in higher densities in certain areas of the scalp provides a "thinner" natural look, but more actual coverage.

In addition, one could theorize that using all 1-2 hair grafts in a certain area could create a different type of density because hair is exiting the scalp .4-.5mm apart, contributing to a progressive density once the hair is styled.

I would guess that 3 single hairs occupying a given area would theoretically provide greater coverage than a single 3 hair graft with one exit point.

 

There is also the idea of a 3-4 hair graft spreading out and providing more coverage, which certainly is credible and accepted.

 

1 and 2 hair grafts providing greater coverage?

Combination of 1,2,3, and 4 hair grafts providing greater density?

Are density and coverage the same?

 

Just some thoughts----- feel free to question them--- these are some ideas I have rolling around.

 

Sorry about the length,

J

[the B spot]

Well, I guess I would like to start writing out some of the ideas or thoughts I have been putting together over the last few months.

 

I would ideally like to take one aspect of hair transplantation and examine it, write out what I think or have discussed with others, etc... and just go from there.

 

Recently, we have been discussing sub follicular division---- we still have no real answer or agreement but setting that aside, I want to discuss some theories I have--- see what you guys think.

 

We are all well aware that hair grows in natural groupings of 1,2, 3, 4, and 4-6 hairs.

Most of us are aware that according to published studies, the normal breakdown of follicular units (in the donor region) is: 15% 1 hair grafts, 51% 2 hair grafts, 29% 3 hair grafts and 5-6% 4 hair grafts (4-6 hair grafts).

 

So using this info (I am aware that patients differ, but for the sake of argument), lets examine a 4000 grafts session using normal published graft distribution.

The breakdown is:

600---- 1 hair grafts

2040--- 2 hair grafts

1160--- 3 hair grafts

200---- 4 hair graft

 

When we look at this we have 2,640 fu's that represent the most refined grafts already, pure and unadulterated in their natural state.

 

What remains are 1360 multi- hair grafts and it is among these grafts that any sub-follicular division would have to take place. (I am not talking about splitting fine 2 hair grafts for hair line work)

 

One of the first issues that immediately appears is the follicular groupings themselves often twist together or grow so closely that they are unable to be split. Of course, one could posit that transecting 1 hair to get 2 or 3 refined 1 hair grafts (out of a 3-5 hair graft) is acceptable, but I would like to assume that this practice is too egregious to consider.

 

When we look closely at these 1360 grafts---- what type of parameter can be set for just how far they can be sub-divided?

 

I think it would be categorically impossible to sub-divide all of these grafts, unless of course the practice of splitting involves risking 1 fu to sub-divide it into 2-3 grafts.

 

I am going to place this at 50%--- no hard data, just theory, gut and willingness to offer a starting point.

 

1360 divided by 2 = 680

Before we sub-divide any grafts we have 3,320 naturally occurring follicular units and 680 3-6 hair grafts that we are preparing to sub-divide.

 

If the 680 grafts are split in HALF(1360)--- the graft total moves to 4,680 grafts

If the 680 grafts are split into 3rds(2060)--- the graft total moves to 5,360 grafts

 

Obviously, the corresponding hair counts will be lower, probably in the 1.6-1.7 hair to graft range, as opposed to the normal 2.2-2.3 hairs per graft.

A greater preponderance of 1 hair grafts should exist as well.

 

Even if my 50% of the "multi-grafts" is off 10-15% either way, it is easy to see how graft totals can be inflated past the yield of naturally occurring follicular units.

 

We see how 4000 grafts turns into 4,680 or 5360 grafts by sub-dividing a relatively small portion of the multi-haired grafts yielded.

 

My next question is---- Is this an altogether bad practice?

 

I think all of us will agree that tightly packing 55-65 1 hair grafts into the first 1-1.5cm of the hairline would look amazingly soft and natural and still provide the density most of us are looking for.

 

What about the frontal core and mid-scalp areas?

What about the lateral humps?

What about the crown?

 

What IF I went to my Doc and said I have 90cm of crown to cover, but I only have 2000 naturally occurring follicular units. (This would cover the crown at about 22 fu cm/2)

However, I asked for them to be sub-divided into 2600 grafts (This would cover the crown at about 29 fu cm/2).

 

The same hair is being moved, but a theory that transplanting 1 and 2 hair grafts in higher densities in certain areas of the scalp provides a "thinner" natural look, but more actual coverage.

In addition, one could theorize that using all 1-2 hair grafts in a certain area could create a different type of density because hair is exiting the scalp .4-.5mm apart, contributing to a progressive density once the hair is styled.

I would guess that 3 single hairs occupying a given area would theoretically provide greater coverage than a single 3 hair graft with one exit point.

 

There is also the idea of a 3-4 hair graft spreading out and providing more coverage, which certainly is credible and accepted.

 

1 and 2 hair grafts providing greater coverage?

Combination of 1,2,3, and 4 hair grafts providing greater density?

Are density and coverage the same?

 

Just some thoughts----- feel free to question them--- these are some ideas I have rolling around.

 

Sorry about the length,

J

[MrJobi]

Great thought

 

I have been asking this question too in a some sense. Personally, I think it's important for doctors to reveal if they do it or not just so we can compare sessions between docs ( also it affects prices greatly). Some people say " I have had 7000 grafts." when in reality it is 5000 split or so.. We must compare apples to apples for results sake. As far as the practice, if they do it and the result is Great, I don't care but. Then again the whole purpose of FU's are for them to remain in a natural state..

In the end, it's all about the result and the honest practice of doctors informing us on the truth

[nobuzz4me]

B-spot,

 

Good topic, no doubt this will become a long thread.

 

My opinion is:

 

I think FU's should stay in their natural state if at all possible.

 

I am against sub-dividing FU's just as I am against DFU's (double folicular units).

 

I would be curious to know the risk of graft survival rates on sub divided grafts? Is there any risk??

 

For someone who had plugs, any thought of a 4-6 hair DFU scares me. I can see if a guy is loaded with one hair donor FUs it may help denisty, but then again that guy may not be the best candidate for HT anyway in that condition.

 

The only justification for sub-dividing is if someone is short on 1's for the hairline.

 

Does anyone know if Bosely or MHR have ever been accused of sub-dividing for higher counts and thus charging more??? Just curious.

[hairbank]

B-

 

Good thread along with a very detailed accounting of your thoughts...........I expect nothing less, bro !

 

I'm a little perplexed?? ? From my prospective, HT's are so subjective, I'm not sure how you can go about defining a methodology for sub division of follicular units.

 

As was mentioned, I think all will agree that many one-hair grafts are needed in the hairline for a more natural appearance. Beyond the hairline...............what is strategically best for the HT patient? "What's best" will often depend on the type of coverage that particular individual is looking for. For instance, a NW 7 will likely be happy with coverage in the midscalp and frontal 1/3, but some may choose to have thin coverage most everywhere in which case more division of follicular units would have to occur.

 

What about the genetics of the HT patient's hair? Fine hair versus thick hair.....straight hair versus curly? There are so many variables when it comes to HT's that the surgeon must not only have the surgical skill set necessary but also possess the artistic ability to create the best possible natural look.........then decide what combination will provide the best result for that particular person. For example, if the HT patient has thick, curly hair, but low density in the donor area, a surgeon may opt to use as many 1 & 2 hair grafts as possible to cover a larger area knowing that the hair characteristics point toward providing better coverage than average/straight hair.

 

There is merit in knowing what you're getting............total hairs versus total grafts. More importantly to me, it's a must to have a clear understanding of what you're looking for then adequately convey that message to your surgeon so he can have a clear picture of what you want to achieve thus opting for the best strategy to achieve your goals.

[the B spot]

Thanks for the replies guys.......appreciate your thoughts.

 

However, instead of necessarily focusing on whether or not sub follicular division is right or wrong--- I want to focus more on the BENEFITS/DRAWBACKS of employing this technique.

 

ie--- 3 single hair grafts occupying an area versus 1-- 3 hair graft in the same relative area.

Does one method provide more "coverage?"

Does one method provide more "density?"

 

I am trying to determine if we need to amend our view of coverage and density as a matter of relevance to discussion or comparision.

 

I am intrigued by this and I want to focus on this alone-- rather than the politics or ethics of certain clinics right now.

 

I think those issues are relevant, but I want to separate the two and attack the heart of the issue TECHNICALLY first.

 

I think we may find something very useful to us here.

Your thoughts?

J

[hairbank]

B-

 

My technically-minded friend, I understand what you're looking for, I'm just not sure HOW we can accomplish this based on the information we have access to .

 

Before I would feel like I was informed enough to say whether 3-4's provided better coverage in the crown than an equivalent number of 1-2's I'd want a side by side comparison so I could appropriately measure the results.

 

One other thing I'll point out, even if a surgeon tells you the number of hairs transplanted along with the number of grafts, the only real way to measure the HT is if you know WHERE they were placed.

 

Using your example above of 600-1 hair grafts, 2040-2 hair grafts, 1160-3 hair grafts and 200-4 hair grafts............I'll assume most or all of the 1-hair grafts were planted in my hairline. Where and how did the surgeon use the other hairs? Were the majority of the 4 hair grafts placed in the crown or midscalp?

 

I guess I would finish by posing the question "How can we actually determine the benefits/drawbacks to sub follicular division"? Do we have enough information for proper assessment of this situation?

[Pat - Community Publisher]

B Spot, Thanks for raising this very topical discussion.

 

As patients become aware of the variations in graft cutting among leading clinics ranging from sub follicular unit grafts (naturally occurring 3 and 4 hair grafts trimmed into 1 and 2 hair grafts) to multi follicular unit grafts (grafts containing more than one naturally occurring follicular unit that are very close together) - the question of the ultimate aesthetic effect of the variations in technique becomes topical.

 

That is why hair counts are really a prerequisite to moving on to more sophisticated discussions like this one.

 

I can see pros and cons with all these variations. Of course, some patients are better suited for some some graft sizes than others (i.e. patients whose hair is thin in diameter can typically get away with larger grafts, while still looking natural).

 

Sub follicular unit grafting does enable the total amount of hairs yielded from a given donor strip to be spread out/disbursed more evenly within the transplanted area. This could potentially produce a greater optic illusion of density and naturalness in some patients - especially during the first session.

 

However, some leading physicians feel that for many patients they can create a greater ultimate illusion of density in the central areas by using 3 and 4 hair follicular units and even a small amount of multiple follicular unit grafts. These physicians believe that such multi haired grafts have the critical density needed for blocking the see through look that might occur with even large numbers of smaller one and two hair grafts.

 

However, in my opinion, if these 3 and 4 hair grafts are not packed at sufficient density they can look some what grafty.

 

Another consideration is that making more incisions to accommodate the additional grafts created from trimming 3 and 4 hair grafts into 1 and 2 hair grafts does increase the linear damage to the scalp.

 

However, the impact of these additional incisions is dramatically minimized by the very tiny and superficial incisions which can be as small as 0.7 mm for one hair grafts and 0.9mm for two and even three hair grafts.

 

Consider also that by placing a 2 or 3 hair follicular unit graft into a 0.9 mm insicion versus 3 separate one hair grafts into three 0.7 mm incisions the multi hair graft can reduce the impact of incisions on the scalp's vascular (2.1 mm of linear incisions for three one hair grafts versus one 0.9mm linear incision for an ultra refined three hair graft).

 

Also if a patient's objective is to maximize their dense packing of hairs in a given area are they better off using grafts that already contain hairs that are in a dense distribution because they are bundled together versus or use many 1 and 2 hair grafts inserted close together? Impressive sounding counts of 60 plus grafts per cm2 are easy to achieve is you're only using one and two hair grafts. But what is the real optical density of such so called "dense packs".

 

I'm impressed by many of the results I see from leading clinics using both follicular units and sub follicular units. Which variations in technique ultimately produce the best cosmetic outcome and value? At this point I think the jury is still out.

 

However, I will remain a vocal advocate for large (5,000 or more hairs) ultra refined follicular unit graft sessions in which the smallest possible incisions are used to enable both dense packing and minimal impact to the scalp. I will also continue to advocate hair counts and better photo documentation from all angles and stages of the hair transplant process.

 

Ultimately I hope that all who visit this community find the detailed and accurate information they need to make the right informed decision for themselves.

 

Best wishes, Pat

[MrJobi]

Hi all

 

One of the best post's I've seen. My whole perspective is to compare apples to apples.. Often people say I have 5000 grafts when in reality they have about 3500 FU's split.. This is not a fair comparison and the only reasons I wish the docs would reveal if it is done. This way we can compare and benchmark accordingly. For me, it's all about the results.

 

AND as Pat say's

 

Count hairs not grafts!!

[YoungGuy]

Ah, let's not split hairs... it's all FUs anyway

 

(Sorry, couldn't resist this particular joke!)

[Bill - Seemiller]

I think FU's should stay in their natural state if at all possible.

 

I agree with this statement.

 

I think sub-dividing of grafts ultimately will lead to less density since there are simply less hairs. In all honesty, I can't think of anyone who will actually dispute these facts.

 

Ocassionally I can think of reason to sub-divide, when more single FUs are needed for the hairline, etc...however making this a general practice not only lessens density, but if you are charged per sub-divided grafts rather than per FU, one could argue ethics as well.

 

Bill

[Gorpy]

One thing I am noticing is that there is a definite effort to please the customer with harder, thicker hairlines. You see doctors bragging about 50, 60 and 70 or more grafts per cm2. They are obviously talking about 1 and 2 hair grafts at that density (I think it is virtually impossible to plant larger 3 and 4 hair grafts at that density), and of course, you would only use 1 and 2 hair grafts in the hairline area. As the need for 1 hair grafts rises with rising density demands, doctors have no option but to split more of the larger grafts.