What is the optimal Ultra Refined Follicular Unit procedure?

[nikkop23]

wow, Landen, brilliant uncovering of a contradiction (in your own mind). you can support disclosure of hair counts in principle for the education of all patients while still not being personally hung up on them as long as results are good. now why don't you just SHUT UP already? your posts are getting to be a real drag and waste of everyone's time, and i would rather read productive contributions to this thread than your petulant and overly literal reading of other people's prose. put a sock in it already, bro ....

[Bushy]

Originally posted by Janna:

Hi Bushy,

 

I absolutely agree with you that 9000 or 9200 hairs won't be much of a factor in the long run. It's really in cases where a patient receives 6000 hairs rather than 9000 hairs. One of my concerns in my original comment is when patients see results like Bobman's, they feel that is the norm when Bobman obviously had great density with the optimal hair characteristics for a HT. I'm also sure he had great hair count. It's really for the patients who have lower density that hair count becomes a bigger factor. This helps everyone in reaching a realistic goal.

 

OK,maybe Joe, you, Pat or other experts (Dr. Hasson?) can comment here. My understanding is that H&W do give you a hair count, just not a precise one because they count 1's and 2's but then bunch multiple grafts (3's and 4's) together. I may have this wrong, but that's what I thought. Accordingly, the variation would be minimal, not 6,000 to 9,000. Am I understanding this correctly? I thought even Pat had posted something to the effect that the difference would be relatively slight.

[Pat - Community Publisher]

Dr. Bobby Limmer asked me to post the below message from him on our forum. In the below post he shares his concerns about graft survival when grafts are transplanted in densities in excess of 30 grafts per square centimeter.

 

Dr. B.L. Limmer is a true pioneer in follicular unit grafting and introduced the use of microscopic dissection of donor tissue into follicular unit grafts in the late 1980's, well before follicular unit grafting was adopted by other clinics. His early pioneering follicular work garnered him the nick name "Godfather of follicular units".

 

 

For 18 years, since the first case of follicular unit transplantation was done in our office, we have counted the number of follicular units present per square centimeter in the donor area preoperatively. We have also counted hundreds of cases of individual hairs present in the donor area. We know from this data that the average hair transplant case has 97 follicular units per square centimeter in the occipital donor area. We also know that the distribution of 1, 2, 3, 4 and rarely 5 or 6 terminal (not vellus) hairs within these units lie in a range approximately 5-20% 1 hair grafts, 40% 2 hair grafts, 30% 3 hair grafts, and 5-20% 4 or more hair grafts.

 

Additionally, there is a wide range of follicular units from about 50 to 165 units per square centimeter. Those who have the lowest counts (densities) also have much higher percentages of 1 and 2 hair follicular units and the reverse is true also, that is those who have the highest numbers of follicular units per square centimeter also have a higher percentage of 3 and 4 or more hair per unit.

 

By counting the number of follicular units, per square centimeter preoperatively it is a simple mathematical calculation to determine the number of square centimeters of donor surface area required to produce the number of grafts to be done that session. These aspects of hair science are not debatable.

 

What continues to be debated among hair transplant surgeons are the subjects of the size sessions in total numbers of grafts and the density of grafts (number of grafts per square centimeter) transplanted into the recipient area.

 

The debate over size of sessions should be centered about what is best for each individual patient. The debate over transplant density has been studied by multiple investigators and the consensus of these studies is that graft survival is somewhat less when the density exceeds 30 grafts per square centimeter. However, transplant densities of 40-50-60 or more hairs per square centimeter still produce final hair densities greater than those of 30 grafts in spite of a sacrifice of some hair due to lower % survival. This may sound confusing but it is factual.

 

Stated another way, optimal survival of grafted hair occurs at 30 or fewer grafts per square centimeter. However, transplant densities of 40-50-6 pr more grafts per square centimeter still produce greater final densities but do so at the cost of sacrifice of some of the transplanted hair due to a lower overall survival percentage. In those persons with limited areas to transplant and abundant donor hair such sacrifice may be acceptable. In those cases who have limited donor hair and large areas to transplant perhaps lower densities is advisable to avoid sacrificing any irreplaceable donor hair.

 

These debates will likely continue. The best conclusion seems to be that each case is different and what is best for each person needs to be individualized.

 

Bobby L. Limmer, MD/jac

 

[Bushy]

The debate over transplant density has been studied by multiple investigators and the consensus of these studies is that graft survival is somewhat less when the density exceeds 30 grafts per square centimeter.

Which investigators? What studies?

[Pat - Community Publisher]

I have heard several experienced hair restoration physicians voice concerns about whether high density sessions might be masking poor growth.

 

Dr. Limmer in his above post states that -

 

The debate over transplant density has been studied by multiple investigators and the consensus of these studies is that graft survival is somewhat less when the density exceeds 30 grafts per square centimeter.

 

I would like to know more about these studies and who conducted them. For example, did those conducting the studies have experience in performing high density hair transplantation on a regular basis? Did they use small blades some times measuring as tiny as 0.65 mm (rather than the typical 1.50 mm blades used by most clinics)?

 

As Dr. Tykocinski and other practitioners of ultra refined follicular unit grafting have pointed out - the use of very tiny incisions dramatically reduces the linear wounds to the scalp, thus minimizing vascular disruption and trauma. This reduced impact thus enables them to create more incisions closer together without increasing scalp trauma or diminishing growth rates.

 

My sense is that some of those conducting these limited studies had neither extensive experience with high density hair transplantation or ultra refined techniques. Thus I would expect their conclusions would show decreased growth.

 

I believe that in the hands of surgeons who have mastery of ultra refined techniques densities of 40 to 50 highly refined grafts can be successfully transplanted in one session. I base my opinion on feedback over the past few years from both leading physicians and hundreds of patient reports and photos.

 

I welcome any corrections regarding my assumptions.

 

Pat

[Dr. Victor Hasson]

Dr. Limmer,

 

Some of your points are well taken, most notably, that each case is different and the needs of each individual is different. There are however issues which I would like to raise which I feel are quite misleading.

 

Firstly, you state that by counting the number of FU's per square centimeter that it is easy to determine the number of square centimeters of donor surface needed to produce a certain number of grafts. Unfortunately, in real life, things are not quite that simple, especially in a case of megasessions that are increasingly more common. While the number of FU's per cm2 may be fairly constant for a given area in the occipital area in an individual patient the reality is that in sessions of 2500 grafts or more the donor incision is extended laterally into the parietal and temporal areas. There is potentially an enormous amount of variation in the density of FU's taken from the "sides" and "back" of any given individual. I have seen variations of greater than 30 FU's per cm2 from these different areas. So indeed, especially in the larger cases, these aspects of hair science are debatable.

 

Secondly, when you state that lower percentage survival of increasing transplant density is factual, I believe you are overstating the case. All the studies that you quote are in no way close to scientific or statistically significant. We still need decent studies performed by operators experienced with the intricacies and nuances of dense packing.

 

I believe that in certain studies performed by yourself where you have performed sessions subsequent to the initial transplant in the same recipient area (in order to improve recipient density) that the final measured density was somewhat lower than expected (i.e. the sum of the densities planted in each individual session".

 

I would be very interested to hear your explanation for this unanticipated outcome. The question then becomes whether we should attempt to reach a desired density in a single or multiple sessions. I believe that David Seager has demonstrated excellent survival in surgeries performed at higher recipient densities.

 

I look forward to a lively debate.

 

Victor Hasson MD

[Bushy]

OK, Pat here's one study I found. What is a KNU implanter? Doesn't sound like ultra refined follicular unit transplantation.

[Dr. Alan Feller]

If final results are the most important goal, and I beleive they should be, then the case for ultra-megasessions can not be overstated.

 

Until I met Dr. Hasson in 2002, I felt a case should only max out at about 2,000 grafts per sitting. I beleived this because my instrumentation and protocols only allowed 2,000 at a time. The public dialog among HT docs also supported this view. To go any further would have definitely caused necrosis, poor yields, wide scars, and other bad things due to the limitations of THAT TECHNOLOGY.

 

However, after speaking with Hasson in 2002 for ten minutes I learned that there were more refined ways of doing HTs. Lateral slits, custom blades, and extra tumesence were just a few of the "secrets" he generously shared with me. When I tried them I was amazed at the difference in results. Sure, it takes a bit of getting used to, and you do have to increase the size of your staff. But the results are well worth it, and this debate should not lose site of this as I beleive it has. Anyone can de-construct a procedure as Jana, Limmer, and others have to find fault or praise, but the problem doesn't begin there.

 

There is no established terminology in the HT field. For crying outloud we still can't nail down what "vertex" and "crown" actually refer to. Go to several different doctors and you will get at least two versions of each. Without basic terminology, how can we have an intelligent debate? Take the word "follicular unit". What does that really mean? In one office it may mean 3 grafts, in another it may mean 2. It is a useless terminology, as is most of the HT dictionary.

 

My experience to date, after adopting hassons techniques, is even if you divide down what might be termed a "3 hair follicular unit" into 3 single follicles, they will grow with the same yield as if you didn't split them in the first place. This is not a "rip off" or a "cheat" to the patient since it takes considerably more work and skill to do this. And it is far more worth it IF, and only IF, the doctor and staff can pack those grafts close enough to make it worthwhile. I would rather have three hairs evenly but tightly spaced on my scalp coming out of their own single point of origin than three hairs coming out of one slit any day of the week.

 

With that said this does not mean I am a proponent of cutting all grafts down to singles. But, a clinic dedicated to ultra refinement should be able to go the extra step to have an overwhelming majority of 1 and 2 hair grafts over the 3 to 4 hair variety, and then be able to plant them tightly and uniformely.

 

In the end, the only indisputable terminology is the "hair", and I agree with Pat that this should be counted and disclosed along with the amount of donor area removed. Until we move the debate onto this standard there will never be a conversation where the participants are speaking the same language.

 

Dr. Feller

[Cooleyfied]

Well now... I had no idea that posting my HT measurements would lead to such a heated debate but I feel at the end of the day, individual measurements are just that.... measurements of the individual. IMO, it all boils down to donor density.

 

*Example*

 

Gorpy's Count

2700 Total Grafts w/ Keene

663 one's = 663

1116 two's = 2232

721 three's = 2163

200 four's = 800

Hair Count = 5858

 

Cooleyfied's Count

3507 Total Grafts w/ Cooley

1's 1108 = 1108

2's 1744 = 3488

3's 580 = 1740

4's 75 = 300

Hair Count = 6636

 

IMO, the only factual evidence I can pull from this FU/Hair count is one thing.... Gorpy has denser hair than I do. Everyone's hair characteristics are different but I must admit.. it's still interesting to see the count breakdown.

 

And it definitely isn't a way to judge a Dr.'s performance. IMO, what matters is that you're happy with the results. Or at least that's what matter most to me.

 

Cooley, Keene, H&W, Feller, True, Shapiro, etc... with 1000's of satisfied patients, I have to assume they're acting in our best interests to give us a natural head of hair.. regardless of hair count. I mean.. these guys ARE the best for a reason.

 

Moving on... I would like to know more about FU waste % with higher FU# HT's.

[TrOjAn]

Interesting debate on megasessions however I noticed none has expressed his

concern regarding megasession that the person is exhausting most of his donor area

and how will he look 15 to30 years from now?

 

Lets take the example of Jotronic

From his picture and video he is definitely not an old person in 60's or something.

Will he not further bald in the area on sides just next to transplanted area15 to 20 years from now and also his temples which he got restored he will lose some hairs just next to

them in few years. Due to this there will be hair on top and sides and strip in between

with no hair. What statistics do we have to support that he is not going to bald further.

With a megesession he must have exhausted his complete donor area. From where will

He get hair to do some patch up work to fill up this strip in between his transplanted hair and on the sides.

 

Trojan.

[Gorpy]

Thanks for your input Dr. Feller.

 

When you say you "would rather have three hairs evenly but tightly spaced on my scalp coming out of their own single point of origin..." I'm curious, wouldn't the ultimate goal be to mimic nature. Don't they grow naturally in groupings of 1 to 4 closely grouped hairs (what we all call follicular units)? I've seen the magnified pictures. They do seem to grow that way. Would uniformly placing many smaller tightly packed fu's in an area look better due to some still existing technical difficulty with HT's that try to mimic natural occurring fu's?

 

I do agree that post op, due to their uniformity and neatness; they do have an aesthetic appeal. I also agree that both you and Dr. Hasson produce fantastic results. Yet I am curious as to the reasons why that technique would produce better results as compared with placing naturally occurring 1-4 hair fu's.

 

By the way, I'm sure this is a raging debate among doctors.

[Gorpy]

Thanks Cooleyfied,

That actually looks better in my signature

 

Hair counts is just one of many factors. I might have a little more density in terms of hairs, but I also have fairly fine hair, which hurts in terms of hair shaft diameter.

[Garageland]

This is an interesting debate, personally i feel that this hair count is a good idea but will ultimately lead to problems.

Take the two examples posted by cooleyfied

 

Cooleyfied had 778 more hairs than gorpy for instance

 

Cooleyfied paid for 807 more grafts than gorpy

 

These extra paid for grafts were at less than 1 hair per graft!!!

 

So are we to assume that Cooley splits their grafts to produce more one hair grafts as one poster said ripping people off?

 

No we are not, it is down to the patients characteristics.

 

I can see it now, patients bemoaning as to why they got so many single hair grafts, etc etc.

 

We should be looking at results, i can't hear any H&W patients feeling ripped off with their great hair and transformation.

 

Don't get me wrong i would be interested to hear how many hairs where actually moved on my head, but if the final result is great, then will i ultimately be thinking, hmmmmm if only i had a few more 3 hair grafts

[Dr. Alan Feller]

Again, the conversation gets muddled because those involved are not speaking the same language. "Mimicking nature" doesn't necessarily mean COPYING nature as gorpy suggested. It means doing something else with what's available to achieve a result that looks as close to nature as possible.

 

Gorpy, if you were transplanting 50,000 hairs from the donor to the recipient area, then I would say that you were COPYING nature by utilizing the actual groupings as they already exist.

 

However, since we are moving only about 6,000 hairs (in an ultra-megasession) you can no longer attempt to COPY nature because there are so few building blocks to work with. Moving 4 hair follicular units into the recipeint area as such will not be the most efficient distribution of those hairs because you will necessarily have to leave more space between the grafts than you would if a skilled technician could divide that grouping into, say, 2 2-hair groupings.

 

In nature, the over-abundance of hair in the recipient area ensures that the eye will not pick up the bare spaces between the follicular units. As a result, multi-hair units of 3 or more will not appear "stalky". If, however, you removed 80% of the surrounding hairs as may occur during the normal balding process, these "naturally" occuring follicular groupings would indeed begin to stand out and look "unnatural". Fortunately for nature, these hairs begin to miniturize when that level of hair loss is achieved so the "natural look" is somewhat preserved.

 

Hair Transplantation does not benefit from this compensation in hair shaft diameter and so thick groupings of 4 hairs can appear to be unnaturally "standing off" the scalp if there aren't enough hairs between and in front of the 4 hair groupings to prevent the eye from seeing the hair/skin interface.

 

When you have 4 hairs coming out of one slit the slit itself must be larger and the spacing between the grafts must be greater. But when you are dealing with, say, 2 2-hair grafts, the slits can be smaller and about HALF the distance apart. This means the SPACING between grafts will be smaller and less obvious to the eye. Combine this with lateral slit method that allows the hair to almost hug the surface of the scalp and you have a powerful combination of techniques that truly "mimics" nature.

 

Copying nature does not mean you will have the best result. For example, nature's idea of a "shelter" is a cave. Caves were the first human homes.But as we become more technologically advanced we didn't pile rocks and boulders of various sizes on top of each other to create an artificial cave-like structure did we? No, we analyzed the physics of the situation along with the available material and came up with a refind construction method that resulted in shelters that were far BETTER than nature. Would anyone really want a home that looked like a cave just because it mimicked nature? Not in this case.

 

If we had 50,000 hairs available to transplant, then I would agree that we should stick to nature's method. But since we don't, more refined methods are needed to achieve our goal.

 

There are, of course, many other variable that must be factored in when performing HT and deciding how to divide grafts such as hair caliber and density, but overall I believe the best and most consistent results to date have been through ultra mega sessions of between 1 and 3 grafts per grouping.

 

Dr. Feller

[the B spot]

It is not so much of a question of over-paying, or eventual density---- it is question of practice and procedure, and why certain docs (who all produce great results) have lower graft/higher hair counts, than other docs who have higher graft/lower hair counts. I see no reason why a patient would have to pay for naturally occurring follicular units that are "cut" to produce a greater amount of 1's or 2's. If a particular doctor believes that he or she needs to cut 3,4,5,+ NATURALLY OCCURRING FOLLICULAR UNITS, down to 1's and 2's, I feel that is a by-product of this doctors responsibility to produce the finest results, regardless of the methodology he or she chooses. Please note, I am NOT disparaging the practice of sub-follicular division, only looking at it from a different perspective.

This is where the practice of hair moved versus graft count matters (IMO)IF a Dr. harvests 3700 naturally occurring fu's, then that is what the patient should be charged for, regardless of whether or not that count is expanded to 4300, etc...

 

I also think it is ridiculous to think that we cannot transplant safely over 30 fu's cm/2. I wholeheartedly agree that the upper-echelon of HT Dr.s have the ability to transplant in excess of 50 fu's cm/2, but we do need to establish some type of hard data that details survival using the ultr-refined techniques employed by the best. Of course, if data shows that survival at 40 is 100% versus 92% at 60, I would rather do 2 sessions of 30, or 40/20, etc... Until we know for sure, we can only rely on the tremendous results we have seen displayed.

As tighly as grafts are placed, even with .65 incisions, a naturally occurring 3 har graft is more than likely to require less space than that of 3 single grafts. Even with a .65 blade it seems impossible to place grafts closer than 1mm, with respect to existing root transection, and blood supply. I realize that a square centimeter is the equivalent of 100 sq mm, but the question I would like some information on is this: What is the difference between 20--2 hair grafts and 10--3 hair grafts, in a square centimeter, versus 30 single hair grafts? Obviously, using multi-hair grafts 70 hairs are transplanted versus, 30 single hairs, so where is the benefit, other than in the hairline/temple region? Even if you transplant 55 single grafts in a region, using 30 multi grafts still produces more hair in the same region. More hair = more coverage right? Yet one guy can say he has a density of 55, versus the other guy with 30, yet the guy with 30 has more hair. Given the technical skill of top doctors and their ability to mimic the angulation of existing hair, I would like to know how are we to correctly understand density? Is it by graft? By hair? Do we need to break it down to region of the scalp and type of grafts used, in addition to a hair count correllation?

I am not looking for a right or wrong on this, I am just trying assess the different practices and philosophies employed so that we can narrow down density, groupings, placement, etc... so when a patient from Dr. X claims a density of 70cm2 and a patient from Dr. Y claims a density of 35 to 40, we can draw a true comparision. (I also understand physiological make-up, but patients can make that determination on their own (coarse, fine, etc...) Just kicking some stuff that is rolling around in my head this morning

[Hoping]

Question for the group. Dr. Feller apparently believes the lateral cut is the best. I went to Dr. Epstein whom I believe uses the Sagital slit. If I undergo another HT, is there an inherent advantage to the lateral vs. the sagital cut?

[Gorpy]

What Dr. Feller described does make sense, considering a limited donar supply. BUT (a big but), as we all know, only single hair grafts are put up front (hairline), closely followed by the doubles, and finally the 3's and 4's for that very reason. The hairline is more visibly transparent to the bystander, because it is the "edge" of your hair and somewhat exposed. The larger grafts would only be placed behind, where suppposedly there would be enough coverage to not allow a "stalky" look.

 

It's like standing on the edge of a forest with young baby trees on the edge, followed by much denser larger trees the farther you go in. Looking from the outside in, you cannot see the larger trees. All you see is a very dense forest. (thought I'd throw in my own analogy).

[Bushy]

Originally posted by Dr. Alan Feller:

Again, the conversation gets muddled because those involved are not speaking the same language. "Mimicking nature" doesn't necessarily mean COPYING nature as gorpy suggested. . . .

Dr. Feller

 

Dr. Feller, that was one of the most cogent posts I've ever read on this forum. Great cave analogy. And, thanks for clarifying what mimicking nature really aught to mean. Them again, I'm not surprised, considering the kind of results the author produces.

[Bushy]

Originally posted by the B spot:

If a particular doctor believes that he or she needs to cut 3,4,5,+ NATURALLY OCCURRING FOLLICULAR UNITS, down to 1's and 2's, I feel that is a by-product of this doctors responsibility to produce the finest results, regardless of the methodology he or she chooses.

 

I respectfully disagree. Assume that two identically qualified lawyers are presented with the task of preparing the same motion. One puts in 2 hours of research, and spends 3 hours drafting. The other bangs out a stock motion in 45 minutes. Would you suggest both lawyers should charge the same fee? After all, it's the same motion! Indeed, the first lawyer will charge you for 5 hours' work, the other for 45 minutes. Same thing, but one expended substantially more effort and likely produced a superior result.

 

The doctor who spent (or who's technicians spent) additional time dissecting that 4 or 5 hair graft, made finer, tighter, better incisions, then expertly implanted these finer hairs into the scalp should, by the same logic, charge for this additional work.

 

Suppose Dr. Hasson came to me and said, "Bushy, we've got 200 4-6 hair grafts. I can implant them as-is, and you'll have a somewhat pluggy look (as Dr. Feller explained), or I can dissect them into 400 smaller, finer grafts, which will produce a superior result, but I'll have to charge you for this additional work." Do you think for a moment I'd say, "well, Dr. Hasson, I'll take the plugs, thanks?" Think about it. I doubt that the doctors who used to implant big, fat plugs worked from 7 AM to 7 PM as Dr. Hasson did with me (it probably took them an hour or two at most for the 20 plugs). I'll happily pay the man for his time. And if that includes the additional, highly skilled task of subdividing grafts that are too large to create a natural look, then by golly here's my money! That's what I'm there for -- for him to do everything possible to create a natural-looking head of hair, and for me to pay him for every moment he spends doing it!!!

[Dr. Alan Feller]

Gorpy you are correct in your analogy, and that method is the standard by which most transplants have been performed for the last 7 to 10 years. But it is time to move up to the next level of refinement, and this includes a greater number of overall grafts that are spaced a lesser distance apart.

 

Bushy, I appreciate your view and agree that it is correct, however your analogy refers to 5-6 hair grafts which is not the point of this debate. The debate, at it's core, is:

 

Is it better to divide a 4 hair graft down to 2 2-hair grafts and then go to the trouble to pack them tighter and in greater numbers.

 

I don't want to confuse the issue any further with talk of 5-6 hair grafts since NONE of the participants in this discussion would ever advocate the use of such monster grafts (with the usual physiolgical exceptions of nordic hair or extremely curly hair, etc...).

 

That said, Bushy, your point is dead on with respect to the work differential between clinics. A clinic that fails to subdivide appropriately will still get paid the same as those who go to the trouble to do so. And even though both are using "follicular units" they are very different surgeries.

 

Dr. Feller

[Gorpy]

Dr. Feller,

Thank you for your input. It is interesting and quite educational to the patient to hear a discussion of the various HT philosophies.

 

It would even be more educational to hear from a doctor who still believes that placing 3 and 4 hair fu's is the best way to go.

[Pat - Community Publisher]

I do agree with Bushy that if a clinic takes more time and effort to distribute the harvested follicles more diffusely by creating more grafts and incisions then they should be compensated for this work.

 

I also think Dr. Feller makes an excellent point that essentially hair restoration surgery at its best is more about artfully creating the optimal illusion of both density and naturalness - rather than copying nature literally.

 

Many have probably observed that even pure follicular unit grafting does not necessarily look perfectly natural when the density is below 30 or 40 FUs per sq cm for the reasons Dr. Feller pointed out. Transplanted hairs that are growing at full terminal thickness, yet are distributed in thin densities are not optimal in naturalness.

 

Thus I believe a compelling argument can be made that distributing a given number of hair follicles using larger numbers of grafts that are more refined than the standard follicular unit graft may indeed achieve the optimal look of fullness and naturalness.

 

Such an approach is certainly more labor and skill intensive. Thus the work required to achieve this higher level of refinement would need to be reflected in the price.

 

That is why I applaud pricing plans in which the cost per graft diminishes as the graft count increases. Such price plans enable patients to achieve more refinement for a given budget.

[UGLY MAN 4 LIFE]

With regards to splitting the grafts up, would the additional scar tissue surrounding the grafts somewhat limit the proximity of their distribution in the recipient? So basically I'm asking, can you plant them as Dr. Feller suggested without sqeezing them into slits that are too small or in some other way compromising the yield?

[Dr. Alan Feller]

Once again the problem of language blurs the dialog.

Ugly,

1. When you refer to "splitting up the graft" you must define what you mean.

 

In my clinic we do not divide up grafts-ever.

 

We don't just look at a 4 hair grouping and say, hmmmm, I think we'll cut that in half, because at this point it is NOT yet a "graft", it is just an area of strip that is in the process of dissection.

 

Don't confuse a "close grouping" of follicles with a "graft".

 

Sure, there are some patients with follicles so close to each other that you simply can't split them any further down than 3 or 4 hair grafts, but they are quite rare.

 

2. The smaller the incision the less scar you will produce, so there are no "excess scaring" issues when planting many smaller follicular units.

 

In fact, it is beneficial to have the smaller units because their ability to transport nutrients and wastes across the graft (to and from the surrounding dermis) is ENHANCED compared to the larger 3-4 graft variety.

 

3. You should never be squeezing grafts into slits. If you are, the slit is simply too small.

[the B spot]

Should Dr. Feller, or any other TOP surgeon want to be considered with the "rest", then by all means, continue to use the "rest" as a comparision. The initial pricing for 2000-2500 grafts essentially guarantees the time of the surgeon and staff for the day. Many clinics have great pricing for additional grafts after that. I am also not declaring that anyone is being ripped off.

Bushy, I understand your point, but both lawyers would more than likely charge a flat rate for the motion, and then hand any research, etc.. off to their staff. The lawyer that continued to provide better representation could then charge more, while the other guy continues to screw people (I see an interesting corrollary here =) I am saying that Dr.s should not make any money, nor am I saying that I would not pay a premium for a top doctors services. I am saying we better start understanding pricing for graft, versus density achieved, versus what the patient understands is actually happening.

That is my point, which I am directing to the membership here, not at specific clinics, nor as a statement of truth, just a topic to be recognized and debated.

Your argument regarding Dr. Hasson and his using 4-6 hair grafts is flawed from the standpoint that Dr. Hasson has an ETHICAL RESPONSIBILITY to provide the BEST hairtransplant his abilities will allow him. The same goes for any other doctor. IMO, there is no choice anymore to use these pluggy grafts, and any doctor that does is violating the Hippocratic Oath. That is my point, because you and many others still act like doctors have a choice to provide us with the best. I do not. I consider it a responsibility, especially if a clinic or particular doctor is considered a leader in the field.

Again, I am not aiming this at you in particular, or anyone else, just looking at things from a different angle.