HTs and the "illusion of density"

[yesplease]

Much of what I read and hear about HTs is in regards to "expectation management" and the "illusion" of having a head of hair when you undergo a hair transplant.

 

I'm wondering if people can expand on this concept a bit. Does this mean that even the best HTs are still readily detectable to those who are familiar with this process? What makes HT scalp coverage an "illusion" versus a reality? Is it that a HT never produces realistic density? Does a HT ever produce a truly undetectable result?

 

I have perused many threads on here and have scrutinized many of the post-HT photos. Obviously there is a spectrum of results in that some do not produce a very natural result and some look great. Of course it is always going to be harder to really tell when just looking at photos vs seeing a result in real life, so maybe some of you who have actually had the procedure done or who have seen many results up close can comment.

 

Thank you.

[thisguy1]

I think it is well explained on some doctor's sites such as Lorenzo. I dont know if we are allowed to do links but google his site.

 

Basically you have 200 hairs per cm2 on ave - obviously that's an average and every human is different. That is not grafts but hairs. So each graft has 1, 2, 3, 4 depending. But on average that might work out to say 80-100 follicular units per cm2 on a non balding head.

 

To get "density" the idea is if you get near 50/cm2 you can create the illusion of "near" full density. So if you have a small area to cover and are say a norwood 2 you can dense pack 50-60/cm2 in the front hairline or whatnot and life is good.

 

If you have more extensive loss doctors tend to push the higher density at the place everyone sees you (hairline, front third) and then reduce density as you go backwards as only very tall people and birds view you from overhead.

 

As to what is detectable let's just say you will be your own worse critic. Most people will take a glance at your head and if you have a good amount of hair post transplant they are not going to go poke their eyes 4 cm from your hairline and begin counting or notice in certain sunlight its not quite as awesome as a non balding person.

 

So one way to think about it that is simple is 200 hairs/cm2 (nor grafts)is natural density (on average - for dude #1 it might be 170, for dude #2 it might be 220) but if you can get 100 hairs/cm2 (not grafts but hairs) into a spot you can get pretty darn good coverage. Is it identical to a perfect head of hair ? No but its a good coverage and most who are not HT doctors probably wont notice. Now if you are at 35/cm2 on midscalp or crown will be full coverage? No but all this depends on what you have available to donate.

 

FUE actually works in the inverse of this in that unlike strip you are not cutting and sewing an area on back of head - you are plucking out part of that 200/cm2. So the idea is we go into areas where there is that heavy density and reduce it from say 200/cm2 and drop it to 133/cm2 so we "thin it out" in the back and then move those hairs to the front/top. So you reduced the back from 200/cm2 to 133/cm2. Will anyone notice? Supposedly not.

 

So that's the illusion factor - you don't have the same density but the human eye can't detect it because it is just looking at you in general, not under a microscope on your scalp. Other things such as hair length, diameter of your follicles, etc also hurt or help the illusion.

 

Expectation management is if you are a norwood 6 and expect to have your teenager hairline it won't be happening. It's simple math - you have a donor area and a recepient area. So you have only so much hair to give, and have to cover X amount of terrain. So the expectations of a norwood 6 are going to be different than a norwood 2 if both go after 3000 grafts being moved.

[Dutchie]

^^^ summed up perfectly.

 

Having curly hair also helps greatly in the illusion

[yesplease]

Thanks for taking the time to post such a detailed reply. Great info. I will definitely check out Dr Lorenzo's site.

 

So all of that said, what then are the aspects of a HT result that make it "unnatural" aside from the potential lack of density? It seems as though the "pluggy" transplants are a thing of the past given today's techniques.

 

In other words, if you were trying to "spot" a HT, what would be the giveaway? Assuming a guy has good coverage, what is it that allows you to spot a HT from across the room when you know what to look for? From the perspective of someone with a trained eye.

 

 

I think it is well explained on some doctor's sites such as Lorenzo. I dont know if we are allowed to do links but google his site.

 

Basically you have 200 hairs per cm2 on ave - obviously that's an average and every human is different. That is not grafts but hairs. So each graft has 1, 2, 3, 4 depending. But on average that might work out to say 80-100 follicular units per cm2 on a non balding head.

 

To get "density" the idea is if you get near 50/cm2 you can create the illusion of "near" full density. So if you have a small area to cover and are say a norwood 2 you can dense pack 50-60/cm2 in the front hairline or whatnot and life is good.

 

If you have more extensive loss doctors tend to push the higher density at the place everyone sees you (hairline, front third) and then reduce density as you go backwards as only very tall people and birds view you from overhead.

 

As to what is detectable let's just say you will be your own worse critic. Most people will take a glance at your head and if you have a good amount of hair post transplant they are not going to go poke their eyes 4 cm from your hairline and begin counting or notice in certain sunlight its not quite as awesome as a non balding person.

 

So one way to think about it that is simple is 200 hairs/cm2 (nor grafts)is natural density (on average - for dude #1 it might be 170, for dude #2 it might be 220) but if you can get 100 hairs/cm2 (not grafts but hairs) into a spot you can get pretty darn good coverage. Is it identical to a perfect head of hair ? No but its a good coverage and most who are not HT doctors probably wont notice. Now if you are at 35/cm2 on midscalp or crown will be full coverage? No but all this depends on what you have available to donate.

 

FUE actually works in the inverse of this in that unlike strip you are not cutting and sewing an area on back of head - you are plucking out part of that 200/cm2. So the idea is we go into areas where there is that heavy density and reduce it from say 200/cm2 and drop it to 133/cm2 so we "thin it out" in the back and then move those hairs to the front/top. So you reduced the back from 200/cm2 to 133/cm2. Will anyone notice? Supposedly not.

 

So that's the illusion factor - you don't have the same density but the human eye can't detect it because it is just looking at you in general, not under a microscope on your scalp. Other things such as hair length, diameter of your follicles, etc also hurt or help the illusion.

 

Expectation management is if you are a norwood 6 and expect to have your teenager hairline it won't be happening. It's simple math - you have a donor area and a recepient area. So you have only so much hair to give, and have to cover X amount of terrain. So the expectations of a norwood 6 are going to be different than a norwood 2 if both go after 3000 grafts being moved.

[thisguy1]

Yes techniques very diff now than 20 years ago.

 

With the skilled hands of top doctors no one should know you have a hair transplant. The lack of density won't be because someone thinks you have had a transplant. It could just as easily be that they think you have lost some hair. When you have an area covered by say 35/c,2 it wont lead someone to say "oh a hair transplant" - it will just lead them to think "oh there is some thinning there." But they will assume it is just a natural reason.

 

That "pluggy" look I have only seen on some horror stories such as the one clinic in Colorado.

 

If you have good coverage there is nothing that should look unnatural at all. Take the time to look at photos submitted by patients and doctors in these threads and decide for yourself. Hasson & Wong, Konior, Cooley, Rahal, Bisanga, Feriduni, Shapiro, etc... find patients with those threads and look at the "after" shots of people who have had at least a year of recovery and you can see the results for yourself. If you walked by those people out and about on the street and wouldnt take a 2nd look then your questions are answered. That doesn't mean in every case a person won't have thin areas - some will due to extent of loss and what they have available to donate. But they won't look "unnatural".

[gillenator]

thisguy1 just provided some of the most comprehensive and informative posts in this forum! Good job.

 

The only other things I would add would be this: HT surgery is an optical illusion, period. The goal is never to replicate virgin density. Why you ask? It's simply not necessary for most individuals. The basis or platform for HT surgery is to attain the illusion of coverage as artistically pleasing as possible, nothing more.

 

Now, the hair count averages that thisguy1 provided are pretty spot on to serve as an overall average yet many individuals contain a deviance from those numbers either on the plus or downside of things. It's a curve with acute swings.

 

What I have found is that if the surgeon can replicate 50% density on the patient from his native level, he will look normal or restored to "what he used to look like". Obviously this is not 100% the case for everyone but as was stated, overall density levels are going to vary from individual to individual. So if an individual is on the lower curve for overall scalp density, you would not want to graft his frontal zone at 50 FU cm2 or higher because it would not look natural. It would look too dense as compared to his overall scalp density.

 

The other thing is what Dutchie mentioned. Yes, hair characteristics can present and impact a significant part of attaining that illusion of coverage such as a nice wave or curl characteristic as compared to straight hair.

 

Last comment. Hair shaft diameter (caliber) differentials play a bigger part in attaining the illusion of coverage than the average person may think. One doctor that I used to work for continually states that hair caliber is the single most critical factor considered when determining the illusion of coverage. As hair caliber increases, so does the visual coverage.

 

So one could conclude that hair with optimal hair caliber along with a nice wave or curl are the ideal hair characteristics to produce that coveted illusion of coverage...

[Dutchie]

If you're a Norwood 6 or 7 you will most likely need 2 HT operations to achieve density illusion.

 

One is unlikely to cut it. Too much area to cover

[HairLostYears]

illusion of density - huh?!...I'm going to be paying all this money for a @#$%ing magic trick??

 

stripped out - harsh...are they removing busted screws from people's heads?

 

clinic - has always sounded sooo fly-by-night to me

 

^^ Three terms that were off-putting to me when I first started lurking/posting on these sorts of forums. I'm a creep/I'm a weirdo though.

 

Great breakdown, thisguy1.

[gillenator]

Norwood 6's will need more like 3-4 procedures unless your goals are more conservative.

[yesplease]

As far the "illusion" terminology goes, I agree. That's part of the reason that I started this thread. Trying to get a grasp on the limitations of HT and the "best case" results. It's such a huge investment of time, money and emotion, it's hard (for me anyway) to really take the plunge if a good result is actually just an "illusion" of having hair. Makes me think that you can actually tell a HT when you see one if you know what you're looking for, which is a result I really don't think I could take such an enormous gamble for.

 

illusion of density - huh?!...I'm going to be paying all this money for a @#$%ing magic trick??

 

stripped out - harsh...are they removing busted screws from people's heads?

 

clinic - has always sounded sooo fly-by-night to me

 

^^ Three terms that were off-putting to me when I first started lurking/posting on these sorts of forums. I'm a creep/I'm a weirdo though.

 

Great breakdown, thisguy1.

[HairsGone]

Norwood 6's will need more like 3-4 procedures unless your goals are more conservative.

 

How many grafts on average will a NW6 need in total for full coverage at an average density?

[thisguy1]

How many grafts on average will a NW6 need in total for full coverage at an average density?

 

I read a good rule of thumb is take your Norwood # and multiply by 1000 to be conservative and 1500 to be aggressive. I don't think that is far off; of course you could be off by 1000+ for any individual case up or down.

 

i.e. NW6 = 6000 - 9000.

 

That's a wide range but I've seen some diffuse NW6 on here that have a hairline / forelock who if I passed on the street and I was not taller on them I'd think were NW2. But then if you were a bird or a basketball player you'd look down on them and see a lot missing. So they have loss as a NW6 but since its diffuse it is different than NW6 who has massive regression, no hairline, horseshoe pattern. Hence why the range.

 

And again everyone's hair characteristic is different - 6000 for guys with thick hair and olive skin with brown hair is different than 6000 for guy w/ fine hair with black hair on pale skin.

 

I'd also add the crown coverage is a big wildcard. Hairlines are hairlines and midscalp is midscalp. Where people can lose a lot of grafts is in the crown - some people get good coverage with 1200 grafts, other people I've seen on here put 2500 in crown and it doesn't look much different than the 1200 graft guy. That is the place where you seem to have the most variability from case to case.

[Dutchie]

Thats why I think you should always mix in beard-hair with your crown transplant.

So something like 1,000 scalp hair grafts and another 1,000 beard-hairs.

 

2,000 total should fill up most peoples crowns

[HairsGone]

When Gillenator stated most need 3-4 transplants, was he referring to FUE? As I would assume most NW6 can get the required number of grafts in 2 FUT's?

[Melvin- Admin]

When Gillenator stated most need 3-4 transplants, was he referring to FUE? As I would assume most NW6 can get the required number of grafts in 2 FUT's?

 

Not everyone can have two huge strips, some may get 4,000 via strip then find that they can no longer get big strips because of the elasticity. Special cases can get two 4,000 grafts strips but that is definitely not the norm. Generally most guys will have to get 3-4 procedures regardless FUT or FUE.

[esrec]

This is turning into one of the more informative threads in a while. Good stuff.

[Dutchie]

Not everyone can have two huge strips, some may get 4,000 via strip then find that they can no longer get big strips because of the elasticity. Special cases can get two 4,000 grafts strips but that is definitely not the norm. Generally most guys will have to get 3-4 procedures regardless FUT or FUE

I'm such a case. H&W managed to get 4,200 from my FUT, but Dr. Hasson said my next operation would have to be FUE because I dont have the laxity for a 2nd FUT.

 

Thats fine by me cause I hated sleeping on that darned scar last 2 weeks

[Spanker]

I don't really like the term illusion either. If you can understand that your hair density will be less that natural before balding, there you go. A lot of people use that term, but I'm not really about it I know that the hair is less dense than when I was 15, and your doctor should tell you that.

 

 

I agree with the above that your hair should not look transplanted, even if you lose more.

 

I also agree that hair shafts diameter is one of, if not the most important part of coverage. Coverage is done through hair mass or hair volume. When you do your own math, you'll find that difference of hair mass greatly varies between say a 60 micron hair and an 80 micron hair, times 6000 hairs, times 2 to 3 inches really makes a difference in how much hair mass is on top of your head and blocking the light from bouncing off your dome.

[Melvin- Admin]

I'm such a case. H&W managed to get 4,200 from my FUT, but Dr. Hasson said my next operation would have to be FUE because I dont have the laxity for a 2nd FUT.

 

Thats fine by me cause I hated sleeping on that darned scar last 2 weeks

 

Yes great example of what I was talking about, too many times I see people assume or generalize that every guy can get 8,000 grafts via FUT alone, this is simply not the case in most situations, there are those freaks that can get 8,000-10,000 grafts I believe Bill is one of them.

[Spanker]

When Gillenator stated most need 3-4 transplants, was he referring to FUE? As I would assume most NW6 can get the required number of grafts in 2 FUT's?

 

A lot of people can't get 4k strips, and even more can't get 4 strips twice. I have crazy laxity buy a little but lower density with some miniaturized hair throughout the donor. I probably have 6k in strip plus another 1500 in fue if u was willing to go that far. I am happy with my 2k I have already taken for now.

 

But to answer your question, I think some nw6 guys could get finished in 2 and a lot in 3. It depends how aggressive your doctor is with your donor. We are now seeing up to 4k fue cases, which I think is a little risky, but 2 of those and you are tapped out, or a 4k strip and a 2500 fue ando you could be tapped out, so there areally ways to finish a nw6 in 2 years.

 

However if sides drop later they may want a touch up to bridge the gap.

 

Low NW levels who get a transplant early in the balding pattern will also likely have more HT's over a lifetime. I am shooting to be 40 before my next procedure touch up and that will be my second. It will likely be a small procedure, so I could end up with 5 or 6 procedures before I'm tapped out or dead.

 

The numbers of surgeries will greatly vary.

Edited February 20, 2016 by Spanker

[harryforreal]

So all of that said, what then are the aspects of a HT result that make it "unnatural" aside from the potential lack of density? It seems as though the "pluggy" transplants are a thing of the past given today's techniques.

 

There are very few photos of HT's that look natural to me - especially now that I've had a HT and know what to look for and not to simply be "awed" by hair covering an area that was formerly thin or bald.

 

I really dislike the look of mine, and in fact I'm not even sure if I really needed one or if some meds might have simply helped to fill it up just enough - but too late now!

 

For me the things I don't like are the pluggy look of 2's and 3's along the front of my hairlines - in fact, I am planning on having electrolysis done on these in another couple of weeks. Interestingly, Bloxkham and Feller just shared a repair case where a guy's hairline had been made of all singles essentially and looked too thin. When I look at the vidoe, the repair looks very good, however, I can definitely see larger grafts, especially on the patients right temple I noticed. But overall it's very good - again, the question is does it ever look totally natural, and my view is "no".

 

Also I HATE the dark color of the transplanted hairs at the front of my hair line - AND their thickness, even the singles. They are simply too thick and dark to be at the front of the hairline - it looks like beard stubble when shaved down. What's really annoying (depressing?) is the beautiful soft golden hairs I see behind these damn dark black stalks. I used to love the way the golden hairs whisped around my face. Now I've got black, curly pubic hairs across the front of my hairline. WTF?!!?

 

Yeah, I'm pretty down on HT's unlike many of the other guys on here. HOWEVER, obviously some people are happy with their results. But I feel obligated to speak and provide the other side of the coin - especially about some of the things I never imagined before I had the HT - like black, curly hairs across the front of my forehead! I mean, if I was a dickhead to people in life it might be appropriate!!!

 

But most people think I'm pretty nice...

[thisguy1]

There are very few photos of HT's that look natural to me - especially now that I've had a HT and know what to look for and not to simply be "awed" by hair covering an area that was formerly thin or bald.

 

I really dislike the look of mine, and in fact I'm not even sure if I really needed one or if some meds might have simply helped to fill it up just enough - but too late now!

 

For me the things I don't like are the pluggy look of 2's and 3's along the front of my hairlines - in fact, I am planning on having electrolysis done on these in another couple of weeks. Interestingly, Bloxkham and Feller just shared a repair case where a guy's hairline had been made of all singles essentially and looked too thin. When I look at the vidoe, the repair looks very good, however, I can definitely see larger grafts, especially on the patients right temple I noticed. But overall it's very good - again, the question is does it ever look totally natural, and my view is "no".

 

Also I HATE the dark color of the transplanted hairs at the front of my hair line - AND their thickness, even the singles. They are simply too thick and dark to be at the front of the hairline - it looks like beard stubble when shaved down. What's really annoying (depressing?) is the beautiful soft golden hairs I see behind these damn dark black stalks. I used to love the way the golden hairs whisped around my face. Now I've got black, curly pubic hairs across the front of my hairline. WTF?!!?

 

Yeah, I'm pretty down on HT's unlike many of the other guys on here. HOWEVER, obviously some people are happy with their results. But I feel obligated to speak and provide the other side of the coin - especially about some of the things I never imagined before I had the HT - like black, curly hairs across the front of my forehead! I mean, if I was a dickhead to people in life it might be appropriate!!!

 

But most people think I'm pretty nice...

 

Harry I respect your views and each is entitled to their opinions.

 

I checked your profile and see you are a 2A - i.e. very little loss. Most of us advanced cases dream of being a NW2 when it is all said and done.

 

So I often wonder how the NW2 NW1s I see here who put 2000-3000 into their hairlines (i.e. "first world problems") would change their views if they were NW4 at age 30 and NW5 by mid 30s etc. For a lot of people (hand raised) even being a NW3 will be like taking back the clock 10 years.

 

So maybe your view might be a little different if you were one of the advanced cases rather than a borderline need.

 

I also think the casual human being doesn't notice the type of things guys who sit on the internet and stare at hairline after hairline for hours and months on end as they research HT will. Example for me - Dr Diep on here has hairlines I am wowed by...then I read other guys who are upset by them and the zig zag "style" he uses. So I went back and had to look 4-5 times very very closely and notice what they are talking about. But I still like the end result. But these tiny things I would not ever notice if I worked with a guy or hung out with him. I just don't stare at people's hairlines like that in real life - I just look at the head of hair. But maybe I dont have the same attention to detail as some of you - in fact i know I don't

 

p.s. With all that said, how did you get "black curly hairs" on your hairline? Did it come from other parts of your scalp? If so it seems strange that golden straight hairs elsewhere morphed into black curly hairs once they were transported - considering they are identical hair, just moved to a new place. Have you documented that here - I'd be curious to see as I have read 100s of threads the past few years and havent seen the hair change color and form like that once you get past 12 months.

[harryforreal]

...maybe your view might be a little different if you were one of the advanced cases rather than a borderline need....So I often wonder how the NW2 NW1s I see here who put 2000-3000 into their hairlines (i.e. "first world problems") would change their views if they were NW4 at age 30 and NW5 by mid 30s etc.

 

I do agree with your sentiment completely, and that is why I have never come out with a blanket statement against hair transplants. For some guys it is a great thing for sure, and I definitely respect that and understand it.

 

At the same time, however, someone like myself who is noticing the first signs of thinning hair (@ age 40 or 41 I believe at the time), if we check into a site like this and see all kinds of rave reviews about the naturalness of hair transplants and how happy guys who've had a HT are, we might get the wrong impression.

 

I know I certainly had the wrong impression after I walked out of my consultation!

 

You know, you see on TV - from Oprah to Dr. Oz - all the time about hollywood stars having plastic surgery and hair transplants and etc, etc, and you think - "Wow, all it takes is money to look like a star!" It seems so easy to look perfect.

 

I literally thought from seeing Bosley commercials on TV growing up that in one afternoon you just took hair from the back of the head, moved it to the front, and walked out that same afternoon with an amazing looking head of hair ready to hit the club that night! It looked so easy!!!

 

Yeah....I know...pretty uninformed!!!!

 

So my main purpose in sharing another view is that it aint' so easy, and it doesn't look so perfect. Then guys have to decide for themselves if it's right for them - and that's before any potential complications (which I also had - permanent redness for 5+ years in a band along my forehead!!!).

 

That being said, a NW 5 or 6 isn't going to have much in the way of softer, lighter hairs along their hairline, so a large HT might not have two distinct color zones like I feel I have.

 

As for who will notice, well, when I have a date reach up into my hairline and run a finger through the transplanted hairs while bending in for a closer look - that's where the real problem is (ugh, last summer!). Though I certainly feel I have had the occasional perplexed, strange stare from someone standing at a check out counter as well. If I were married and were considering a hair transplant as some guys on here, I also think that might be a different story. In this type of circumstance the person who matters most to you - your wife - already knows what you are considering doing. But trying to date with a HT is a real concern, this I tell you, especially if it looks bizarre.

 

With all that said, how did you get "black curly hairs" on your hairline? Did it come from other parts of your scalp? If so it seems strange that golden straight hairs elsewhere morphed into black curly hairs once they were transported - considering they are identical hair, just moved to a new place. Have you documented that here - I'd be curious to see as I have read 100s of threads the past few years and havent seen the hair change color and form like that once you get past 12 months.

 

I definitely think some hairs actually got thicker and darker, though others on here surmise that it's just hairs coming from areas of the scalp where the hairs are naturally thicker and darker (for clarification my hair is naturally wavy/curly, so that's where the curl comes from). However, I've plucked the transplanted hairs and compared them with native hairs from the back of my head and the transplanted hairs are definitely thicker and darker. But even this aside, the soft vellum hairs along the hairline are naturally lighter and finer than hairs from other parts of the scalp. It's a bizarre look, black hairs in front, blonde hairs (now graying) behind them. Perhaps if I had been completely gray at the time the contrast would not have been so noticeable - but I'm not sure about that. I keep hoping that eventually it will all soften up and blend, and in fact I am hoping that MAYBE the electrolysis will lighten these hairs and make them finer without getting rid of them completely, but even if they do go completely, quite frankly I think it will look better than at present. The transplant part works - it can be done; aesthetically it's the worst hair styling I've ever had - quite shocking to me. Just doesn't make sense to me aesthetically - I honest to God can't figure out what the aesthetic goal was.

 

And yes, actually, I have documented the darker hairs and had discussions with other guys on here who've complained about the same thing. I'll post a couple links to those photos and discussions.

[harryforreal]

On this thread you can see some photos from a couple weeks ago:

 

http://www.hairrestorationnetwork.com/eve/182288-hair-transplant-reversal-2.html

[Dutchie]

There are very few photos of HT's that look natural to me - especially now that I've had a HT and know what to look for ......... the question is does it ever look totally natural, and my view is "no".

 

Yeah, I'm pretty down on HT's

Just to get an idea of what your HT standards are, could you please point out in this video which transplants you think look unnatural: