Realistic Expectation for Dense Packing?

[corvettester]

What's considered a realistic expectation for dense packing? I've heard people claiming up to 80 grafts psqcm! But I thought most people had 90 naturally? And according to the HTN multimedia animation, it only take 45 to give the illusion of fullness.

 

Also, what factors contribute to how dense a doctor can pack? Does hair shaft size have anything to do with it? Scalp laxity? Any input would be greatly appreciated.

 

I'd love to hear some of the communities opinions on this matter. I'm getting my HT in about a month so I want to know what I can realistically hope for.

[weweregods]

Several factors figure in to how dense a doc might pack an area receiving the transplant:

 

1) hair characteristics - if the hair diameter is large, course, and of a wavy texture, they won't need to pack the area as dense because these characteristics help with the illusion of density

 

2) density of the donor - if the donor area is dense, then there will be more grafts to use for transplanting, which may factor into the decision to pack denser. Not everyone has 90 grafts/sqcm, some may have much more and some much less

 

3) density of natural, non-miniaturizing hair - if the doc transplants denser than the surrounding hair, the transplant will look strange... ideally, the doc wants to create the illusion that will blend the natural and the transplanted hair in a smooth way

 

4) scalp laxity - the laxity of the scalp also factors into how dense the transplanted area will be as it may limit how many grafts may be taken from the donor

 

5) positioning of the hair - some docs can transplant the hair so that they grow parallel to the scalp and may, for instance, design a hairline that--at least in some areas--appears denser because it grows very near the scalp and may not need to transplant as dense

 

6) technique - some docs have designed special instruments that allow them to transplant higher densities than others--this is one of the MOST important factors in considering a doc, as some docs use huge scalpels and can only transplant at low-density. Many hair mill chains even use multiple-bladed tools

 

7) area to cover - the more area you have to cover, the lower the density MAY be because of the limitations of your donor and potential for future loss

 

8) potential for future loss - if you lose more hair, you'll want to have grafts left in the donor for another transplant and you'll may need another if you lose hair behind the transplanted area. There can be no guaranty that you will not lose more hair, so they want to make sure that the area will look as natural as possible if you lose hair behind the grafts

 

9) age of the person getting the transplant - the younger the person is, the more time they have to lose more hair

 

10) history of hair loss - this includes family members that have a history of loss (how much hair they lost, their pattern, and when their loss started) and how long the patient has been losing hair, their pattern, how much hair they've lost in that time, etc. in considering how aggressive they may be while still being a bit conservative

 

11) medication history - the doc will want to know how long the patient has been on hair loss prevention medications like Rogaine and Propecia, etc. to judge if hair loss has stabilized

 

12) patient expectations - the doc must keep the patient's expectations within reason considering all the factors above

 

As you can tell, there are many factors for the doc and the patient to balance before an HT should take place. No matter what, an HT is always a bit of a gamble, but with the right choice of doc, you can make it an educated guess and come out looking great!

[Dr. Glenn Charles]

That post seems very detailed. Do you work for a transplant clinic? If so, you are supposed to disclose that. Either way the imformation was very good. It is also important to remember that different areas on the scalp will require different densities to give the appearence of fullness.

[weweregods]

Nope, Dr. Charles, I don't work for a transplant clinic... yet. Was that a job offer?

 

I'm just a gifted amateur, for the time being. Oh, and thanks for mentioning the 13th factor to consider.

[Zup]

weweregods, I'll support the kudos from Dr Charles and spex.... from Dr Charles, Feller, SMG not bad.

It is important to plan densities around where one will progress too, at SMG, we evaluate our approach around where the patient is, at the moment, but because we are dealing with a moving field and a limited source we also want them to understand what can be achieved worst case scenario, if they progress and go bald.

If the average patient goes bald; average patient has approx. 4000-8000fus in your donor to move, moderate being 6000fus. At our clinic we've been measuring MPA areas for years and we have found average MPA (the top plane of the head) is approx. 200cm2 in surface area. If you distribute 6000fus over a 200cm2 area, the density yields 30fus/cm2. 30fus/cm2 is a density that may have a fuller appearance depending on the characteristics of the hair, so 30 is not bad for someone who would be otherwise bald. Now, how most patients would distribute the hair would be rather then 30fus/cm2 over the entire area evenly and treating everything equal, most would prefer 40fus/cm2 in the frontal half (front 100cm2), a fuller appearance and 20fus/cm2 in the crown (back 100cm2), generally just enough hair to hide the scalp when dry.

Now, as Dr Charles mentioned there is what is called selective distribution; which is by making certain areas thicker you'll make other areas around it appear fuller. Two particular areas: are the frontal core area and anterior crown. By making the frontal core thicker it will make the hairline and everything around it appear thicker, by blocking the light. And, because the crown sit on a slope the hair falls downward, by making the anterior crown thicker, there is more hair to shingle over the remain crown area.

So, if you are an average patient and you show a strong disposition to progress and go bald, and have an interest for complete coverage, one should not exceed these designated densities. If one is not concerned with a bald crown or can be assured they won't go bald either do to genetic predisposition or that meds will prevent it (but this can never to confirmed for sure) higher densities can be achieved.

Regards, Matt Zupan

[Spanker]

I have heard that the survival rate of the grafts drop on anything over 40 grafts per cm2

[gillenator]

I have heard that the survival rate of the grafts drop on anything over 40 grafts per cm2

 

Thanks Spanker. I was about to comment on the yield issues with dense packing. In theory, it's a great idea and obviously more revenue for the doctor/clininc. I have not seen however many clinics that do it well, meaning survival rates or consistently high yields to support the idea.

 

When we get into dense-packing we are talking about literally thousands of recipient incisions being created in one setting. And obviously the more incisions created and the more closer they are in proximity to each other, the more potential tauma that takes place, including swelling.

 

Oh sure I recognize the improvement of using the tiny micro-blading to allow for closer placement of the FUs and depending on the use of saggital/lateral incisions, lots more hair can be moved with less overall trauma and swelling.

 

But even starting with a completely bald surface, I never see the need of getting into 80 plus FU cm2 on anyone. And the better the hair characteristics and hair quality, the fewer grafts needed to achieve the illusion of coverage.

 

I remember when dense-packing was the buzz in these forums about 5-7 years ago and it seemed to die out simply because very few clinics were able to pull it off with high survival and do it consistently.

 

Generally speaking, whenever I have seen patients get above say 60 FU cm2, the corresponding yields go way down. Could that be why we NEVER saw any yields reported or even tracked with these "super sessions".

 

IMHO, I would rather go in and get 40-50 FU done, let it all grow, and then come back for a second pass. Just my opinion.

[Dr. William Lindsey]

Gillinator is right that at some point there is a trade off between density and graft survival. I'm not sure its the same number for all takers, example a health 30 year old vs. a 60 year old with high cholesterol and who smokes. Certainly local flaps and skin grafts heal differently on those 2 patients, and I suspect hair revascularization is different too.

 

Plus not everyone needs the same numbers, as eloquently discussed above.

 

That is why an in person consultation is so important.

 

Dr. Lindsey McLean VA

[hairhunter]

Would 20fu's/cm give enough coverage to the crown and midscalp to pull off a buzz cut look?

[AdamAJ]

hasson and wong are famous for there super sized mega sessions with excellent growth...so why cant all the other surgeons pull it off?

[Spanker]

hasson and wong are famous for there super sized mega sessions with excellent growth...so why cant all the other surgeons pull it off?

 

 

I do not think that they are packing any more dense that then the other top guys.

[YouOnlyLiveOnce]

I agree. Dr. Rahal and armani are the doctors that come to mind when I think of dense packing. H&W are more known for mega-sessions.

 

Rahal was my only other choice when considering a transplant. He packs the hairs a little more dense than some of the other Surgeons but his results are great and it seems he has the patients future in mind.

[Jotronic]

A few years ago we were known for more than just megasessions. Dense packing and H&W were synonymous. However as the word spread we found ourselves with more and more requests for "x" number of grafts per cm2 where it didn't make sense and would be irrational and irresponsible to deliver. Too many times I would receive virtual consultations that stated how many grafts per cm2 the patient wanted when they really had no idea what it meant. They would simply see the numbers posted on the forums and thought that what they read about one patient and their density would apply to them so that was what they wanted to, so come hell or high water they were intent on getting it. Usually these requests were from 21 year old kids or guys with aggressive loss or both and the only thing they truly cared about was high density, whether it made sense for them or not. I remember having to spend more and more time educating patients why 100 grafts per cm2 was not a good idea. We then made the conscious decision to stop pushing the ability to super dense pack as a reason to come to H&W.

 

Fact is though, we literally defined what it is to dense pack. Back in 2002 Dr. Hasson went to the ISHRS conference in Chicago and brought one of his patients to show to the group. You have to remember that at this time the most that some clinics were doing was roughly 35 per cm2 and a lot of docs even considered this to be on the high end. Dr. Hasson's patient was the first known patient to receive 70 per cm2 in one pass. His photos are below.

 

 

 

 

 

This sent shock waves through the conference and all sorts of claims were being made about how this was a "one off" result because of his perfect characteristics. A "fluke" is what was also thrown around so Dr. Hasson said, "Ok, we'll bring 25 more flukes to the conference in 2004 when it is in Vancouver". That is exactly what we did and to this date we are the only clinic in the world to ever bring in 25 patients to the ISHRS hair conference for peer review. This was to silence the critics and to show that we are the real deal, for megasessions, dense packing etc.

 

Below is what was said by the then editor emeritus, Dr. Richard Shiel, of the ISHRS magazine that is sent out to over 700 member clinics. He was discussing the highlights of the event in the issue that came out just after the conference.

 

 

"Meeting Highlights

 

The indeligible image I will take away from this meeting is that of the patients of Drs. Victor Hasson and Jerry Wong. These were demonstrated at the Live Patient Viewing on Friday afternoon.

 

To say that these results were "mind-blowing" would be an understatement. Please picture a young man with over 5000 FUs harvested and planted in A SINGLE SESSION and growing with close to 100% perfection. Not only growing, but planted at up to 80 grafts per square centimeter and giving the appearance of completely normal hair direction and density with no "crinkle" whatsoever and a donor scar of 1-2mm.

 

The rest of us will be a long time catching up with the skills of Jerry and Victor and their wonderful staff of assistants."

 

To be clear and to better clarify the above quote, not ALL of the patients had 80 per cm2 and/or 5000 grafts in a single session because I was one of the patients highlighted but I was shown at the time because back then I was one of the more dramatic repair case turnarounds to be shown with 7500 grafts.

 

Below are two more cases of dense packing and super dense packing.

 

60 per cm2, 8 months post-op performed 8 years ago.

 

 

 

And this patient received 80 per cm2 and is shown one year post-op about 7 years ago.

 

 

 

 

So, while we are MORE than happy to let some other clinics get the attention for dense packing don't think for a minute that we can't do it. Like I said, we literally defined what dense packing is and perform it regularly. Not only can most clinics NOT dense pack like we can there are very few clinics that can come close. Dr. Rahal is certainly among those that can.

[RCWest]

Jotronic, those first 2 photos remind me of Bobman. Is it?

[lorenzo]

Jotronic, those first 2 photos remind me of Bobman. Is it?

 

Ill answer for Joe if that is ok. No that was not Bobman that transplant was done before 2002.

 

 

Ok, we'll bring 25 more flukes to the conference in 2004 when it is in Vancouver

 

Are you sure that was not a 25 off?

[ffar]

I really don't like word "ilucion". And I don't like when people just want to have a "Ilucion". If you do something do it as good as it is possible. I don't want to have a ilucion, I want have head full of hair. Well, patient who had 80 per cm2 looks absolutny natural. So let just say that if i would have NW2(and little thinning) and great donor(can rebild me hairline and cover thinning with 80 per cm2 dense) arena, H&W\Rahal or other who are able to do such big dense like 80 per cm2, will give me this? I can decide how many gafas i want per cm2?

Edited January 13, 2011 by ffar

[Spanker]

I really don't like word "ilucion". And I don't like when people just want to have a "Ilucion". If you do something do it as good as it is possible. I don't want to have a ilucion, I want have head full of hair. Well, patient who had 80 per cm2 looks absolutny natural. So let just say that if i would have NW2(and little thinning) and great donor(can rebild me hairline and cover thinning with 80 per cm2 dense) arena, H&W\Rahal or other who are able to do such big dense like 80 per cm2, will give me this? I can decide how many gafas i want per cm2?

 

I am not crazy about the word either, but it is what it is.

 

I want gas to 95 cents a gallon again too....but is just is not going to happen.

 

I also want Brad Pitt hair...again, prolly not going to happen. (that guy makes me sick).

 

I am a NW2.5, I have more hair then many people on this forum, but I still wnat to be greedy with my grafts cause you never know if you are going to need them at a later date.

 

I think that you and your doctor have to decide what they think you will be like in the future and make a good decision. If you have no one above a NW 2 or 3 in your family, and you are 35 year of with minor temporal reccession, sure, go for high density if it makes you feel better.

 

 

What is most important to me is that it blends naturally and looks natural.

[ffar]

If you cover just NW2\3 with big density ther will by not an "ilucion". So i am lucky. My dad is NW2(little thinning), his dad also(no thinning just nw2) and they are 50 and 80. Are You able to tell me with one clinic is able to give the bigest(the most gafast per cm2) dense packing? H&W, Rahal or someone else?

I will go in worst case when i will be 30. Now i am 22.

Edited January 17, 2011 by ffar

[Thehairupthere]

Most of the reputable surgeons on this site can give you a very high density result, but the reason some limit it to 40-50 per square centimeter is because of blood flow issues, as well as aesthetic reasons, like not having the space in the recipient area to angle the grafts in a way in which it can grow in a natural position; in this case the hairs will grow straight up. So if this is not an issue for you, you can speak to most reputable surgeons and they can provide you with that service.

[ffar]

So if this is not an issue for you, you can speak to most reputable surgeons and they can provide you with that service.

No it not issue for me

 

I also want Brad Pitt hair...again, prolly not going to happen. (that guy makes me sick).

Come on... I absolutly don't believe that Brad Pitt did't do anything with his hair. His Hairline is more pedant\perfect then anything in this world.

Edited January 20, 2011 by ffar

[corvettester]

Bump.

 

I just had to resurrect this thread. I had forgotten all about it and didn't realize that there were so many responses. I have a few more questions regarding dense packing.

 

The issue of dense packing is a delicate one with many differing opinions. Even though, as Joetronic points out, a few clinics have been consistently dense packing for 9 years now, the number of clinics that are well known for it is relatively small (H&W, SMG & Rahal).

 

Hence, my question: is the fact that so few clinics dense pack a reflection of an inability of docs to perform dense packing well or the view among docs that it simply isn't viable for most patients due to potentially lower yields... or both?

 

So, if I understand correctly, it's not necessarily dense packing, but dense packing in one session that is the sticking point here. Take my case for example: I have approximately 35 FU/cm2. Does that mean that if I don't feel like this is enough density for me, I can realistically expect to go back to add another 35 FU/cm2, thus brining my total to 70 Fu/cm2? The fact that I'm adding density in two separate sessions is supposed to negate my chances of poor yield, correct?

 

Also, which specific characteristics qualify someone as a potential good candidate for dense packing? Please view my hair loss blog and tell me if you think I'm one of them or not and why.

 

 

 

Corvettester

Edited May 2, 2011 by corvettester

[largechris]

I remember this thread and have the same questions, I suspect the answer is that no doctor has a complete record of graft survival rates comparing two separate passes to one dense packing session. Hardly surprising, when many of the educated users on this forum travel thousands of miles to go to the best surgeons, then if they arey are reasonably happy 12 months later they're not likely to rush back to have the grafts counted.

In fact the best surgeons are probably a little frustrated when they don't get the chance to follow up in person with people whose lives they've change.

 

Anyway, my other point was to do with Armani dense packing. Don't recall any specific responses from him, but isn't it possible that one of his arguments for aggressive hairlines is that worst case (if baldness progresses and no hair cloning / rep. comes along in the next 10 years) that an FUE procedure could be done to remove grafts in the frontal transplanted area backwards o the crown or temples etc.

 

Ie having too much dense packing at a young age isn't irreversible?

[mahhong]

If Armani did say that about re-distributing grafts, that's pretty irresponsible. I'm no doctor but though I imagine it's feasible, I would also imagine it's high risk, very expensive, a gigantic mismanagement of resources and generally not a good idea. The idea of popping in to continually re-distribute grafts is terrifying I think, not to mention financially impossible for the vast majority of people.

 

corvettester - In response to your posts, my feeling is that most doctors feel that the illusion of density is more important and more realistic than the actual density of an HT. You probably don't see that many because most people are, for one reason or another, ultimately not going to be suitable. Either their balding is advanced or in serious danger of advancing, or their goals unrealistic or overly-ambitious. I don't think any doctor wants an unhappy patient who has 80g/cm2 in a small portion of their scalp, because it reflects badly on the doctor. It's the doctors job to balance all variables and dense-packing will only work if you really are on the money about every factor.

 

In response to your question about multiple sessions, my understanding is that it won't necessarily negate the risk of poor yield, but it can diminish that risk somewhat. in terms of the characteristics I'm not sure 100% what they would be or if you have them, but I would imagine the main factor is a minimal, stabilised bald(ing) area and ample donor hair to cover that at the density required.

 

I think, ultimately though, dense-packing is only an option if you and your doctor are absolutely sure your hairloss has stabilised, your pattern pretty of loss pretty clearly established (and relatively moderate) and the amount of donor more than enough to cover the are at the desired density (probably with reserve in the tank to be safe). But look at it from your doctor's point of view; these factors are usually not very well known and no doctor is going to risk transplanting your hairline and/or frontal third at 60/70/80g/cm2 and then see you progress to a Norwood V/VI and transplant the crown at 8g/cm2 or something silly! A doctor needs to feel comfortable all eventualities are catered for, and first and foremost will nearly always be having enough hair to work with and never over-egging the pudding.

 

I think for most people something around 30-60g/cm2 is always going to be more realistic. You can never tell where your hairloss will end up and super dense-packing is usually just too risky. It gets to a point where the cosmetic benefits are outweighed by the risks and future disadvantages. I think caution and moderation are, unfortunately, always the best strategies - with the tiny hope that you'll be able to overachieve at some point down the line!

[Frank]

I think this is a great thread. Lots of good information. For those researching HTs I think you can clearly see the importance of selecting a reputable physician who will spend time throughly discussing your options with you. There are a lot of factors involved with HT. You can't just look at someone else's photos and say, "I need that many grafts and I'll look like that guy". Thanks everyone for contributing this information.

[corvettester]

Does dense packing increase the risk of pitting and dimpling?

 

Also, does dense packing negate the need for single grafts only in the hairline?

 

 

Corvettester