At what point does the donor area start to look bad from several procedures?

[TheGman]

I just had a 3261 grafts procedure, and I'm considering my options for the future.

 

It is said that a good donor area can hold as many as 8000 available grafts. But what does that mean?

 

When does the donor area start looking thin? What's the issue when you start extracting that many grafts? Is the appearance of your donor area a good reason to refrain from further procedures?

 

Thank you for your replies!

[mahhong]

There's no hard and fast rule, unfortunately.

 

I presume you're talking about FUE (as the donor area remains largely unchanged apart from a thin scar with FUT, even after two or three sessions, so long as it's well closed and the laxity is there). I would say that 8,000 grafts would be an extremely good yield from FUE. The norm is much closer to 5,000 - 7,000 grafts. Most men should be able to get 4.5 to 5k grafts, some men will be able to get 6.5-7.5k. I would imagine some could get 7.5k+ but that's definitely more of an exception than a rule.

 

As to when it starts to look thin, it varies from man to man. Men with higher densities of follicular units per cm2 will generally be able to take more donor before it begins to look thin. Men with good hair characteristics (wide diameter, curly, coarse etc.) will also be able to use more before the donor area begins to look weak.

 

Your strategy is the best one - taking around 2.5 - 3.5k grafts means you can give your donor area time to heal and, when you come to plan a second procedure, you and the doctor can have a good examination of the donor area and a good doctor can make a proper recommendation about how many grafts you have left before the donor begins to look thin. Sometimes it can be surprising - after healing a man's donor area may look surprisingly strong even after 3-4k grafts getting removed. Other times it may look weaker than expected and a more conservative second procedure may need to be planned.

 

The odds are you should have at least another 2-3k left in the donor area before it begins to look thin, but that is just going by the odds and you need that confirmed by a doctor before really planning out the second procedure. You'd be a lucky man to have another 5k available by FUE but it's not totally impossible, just rare. You'd probably have at least another 3.5-4k available via FUT if you were willing to consider that option.

 

Overharvesting from the donor is a real problem so the best doctors will urge caution and be realistic. You should still have a fair bit left for a second procedure, but it's worth erring on the side of caution and finding a good doctor who will be optimistic but also realistic about how your donor is looking and what could be realistically achieved from a second procedure.

[Transhair]

I'd say a good donor area is one with average (white person) hair shaft thickness at 100FU/cm and could be better or worse based on your characteristics.

[TheGman]

There's no hard and fast rule, unfortunately.

 

I presume you're talking about FUE (as the donor area remains largely unchanged apart from a thin scar with FUT, even after two or three sessions, so long as it's well closed and the laxity is there). I would say that 8,000 grafts would be an extremely good yield from FUE. The norm is much closer to 5,000 - 7,000 grafts. Most men should be able to get 4.5 to 5k grafts, some men will be able to get 6.5-7.5k. I would imagine some could get 7.5k+ but that's definitely more of an exception than a rule.

 

As to when it starts to look thin, it varies from man to man. Men with higher densities of follicular units per cm2 will generally be able to take more donor before it begins to look thin. Men with good hair characteristics (wide diameter, curly, coarse etc.) will also be able to use more before the donor area begins to look weak.

 

Your strategy is the best one - taking around 2.5 - 3.5k grafts means you can give your donor area time to heal and, when you come to plan a second procedure, you and the doctor can have a good examination of the donor area and a good doctor can make a proper recommendation about how many grafts you have left before the donor begins to look thin. Sometimes it can be surprising - after healing a man's donor area may look surprisingly strong even after 3-4k grafts getting removed. Other times it may look weaker than expected and a more conservative second procedure may need to be planned.

 

The odds are you should have at least another 2-3k left in the donor area before it begins to look thin, but that is just going by the odds and you need that confirmed by a doctor before really planning out the second procedure. You'd be a lucky man to have another 5k available by FUE but it's not totally impossible, just rare. You'd probably have at least another 3.5-4k available via FUT if you were willing to consider that option.

 

Overharvesting from the donor is a real problem so the best doctors will urge caution and be realistic. You should still have a fair bit left for a second procedure, but it's worth erring on the side of caution and finding a good doctor who will be optimistic but also realistic about how your donor is looking and what could be realistically achieved from a second procedure.

 

Thank you for your thorough answer! How long should it take for me to get my maximum density in the donor area? I need to be able to plan a smallish procedure for the future(around 1500 grafts) while keeping a normal-looking donor area. One of my sides looks over-harvested but it's only been one month.

[TheGman]

I'd say a good donor area is one with average (white person) hair shaft thickness at 100FU/cm and could be better or worse based on your characteristics.

 

 

This was me before the procedure

 

 

11 days after

 

[Dr Blake Bloxham]

Great reply from Mahhong!

 

The general rule with donor "thinning," or thinning in general, is that it becomes apparent after 50% of the native density is lost. This means if you have 8,000 grafts available, for example, it would theoretically look thinner after having 4,000 grafts removed.

 

However, it may be a little more complicated than this for several reasons:

 

1) If you are a bit of an FUE scar-er (and some people do have more noticeable scars than others), the appearance of the scars themselves may make it look thinner even if less than 50% of the available donor is taken.

 

2) Sometimes the harvesting isn't evenly spread, and you'll have patches that are hit harder than others. This is because you naturally hit "good" and "bad" harvesting patches while doing FUE. Sometimes some people take advantage of these "good patches" and steal too many grafts. If so, it leaves a thin patch in this area.

 

3) Remember that it is difficult to really estimate your entire donor supply. This is because FUE utilizes an expanded donor model to harvest compared to where a strip is taken from. If for some reason someone thought you had 10,000 grafts available and took 5,000, but then it ended up that you really only had 8,000, it may look over harvested.

 

4) There is something in FUE called "attempt to success ratio." What this means is that each "scoring" or cutting of a follicular unit graft may or may not result in a successful delivery of the graft. In plain English, this means that you may cut around a graft, but it doesn't come out as an implantable follicular unit in each case (because it rips or tears during delivery). This means two things: 1) it may take more than 4,000 cuts to get out 4,000 grafts (maybe 4,200 or 4,100) so you may have more scarring to get out the number of grafts you need, and 2) sometimes these follicular units grow back and sometimes they don't (depending on how it broke or failed during the delivery). If it doesn't grow back, this is one more area in the back that is "thinned" without giving you a graft to use. So if you had 8,000 grafts, you wanted 4,000, but it took 4,200 attempts to get that 4,000 and only 100 of the 200 failed delivery attempts ended up regrowing in the back, you could have a thinned appearance.

 

Hope this makes sense! Just a few things to consider in your research.

[Melvin- Admin]

Great reply from Mahhong!

 

The general rule with donor "thinning," or thinning in general, is that it becomes apparent after 50% of the native density is lost. This means if you have 8,000 grafts available, for example, it would theoretically look thinner after having 4,000 grafts removed.

 

 

I think he meant 8,000 grafts that could be removed not 8,000 total, I would imagine someone with only 8,000 grafts total in their donor area is not a candidate for surgery. It is said the average non balding male has up to 100,000 follicular units, that would mean that someone with only 8,000 follicular units left would be an extreme Norwood 7. I think a more reasonable number would be 16,000 which would give a total donor capacity of 8,000.

[Bill - Seemiller]

This is an interesting question and you've already been given some excellent responses and answers. I think the word "bad" is relative however, the more strip procedures you have, the greater risk of some minor scar stretching. For example, I've had for hair transplants and over 9600 grafts transplanted. Overall, my hair transplant scar is quite minimal and even wearing my hair at short lengths on the sides and back of my head, the scar is pretty well concealed. That said, my first score was much better than it is now and even when I wore my hair and a one or a two clip, it was barely visible. Now, I typically wear it at a five, six or seven clip and though it is barely visible, shaving it any shorter would reveal a scar. The possibility of shaving my head completely bald is nonexistent at this point for me.

 

Or is no magic number of procedures or grafts however, just know that the more the resources tab, the worse it will look if you shave your head completely. As for me though, I never got a hair transplant with the thought of shaving my head in the future. If I had intentions of doing that, I just would've went for scalp micro pigmentation.

 

Just thought I would share some of my own personal thoughts.

 

Bill

[Dr Blake Bloxham]

I think he meant 8,000 grafts that could be removed not 8,000 total, I would imagine someone with only 8,000 grafts total in their donor area is not a candidate for surgery. It is said the average non balding male has up to 100,000 follicular units, that would mean that someone with only 8,000 follicular units left would be an extreme Norwood 7. I think a more reasonable number would be 16,000 which would give a total donor capacity of 8,000.

 

Hey HT,

 

Where did you read that the average non-AGA male has 100,000 follicular units (FUs)? The numbers I've always reviewed state that the average non-AGA male has about 100,000 follicles. With the average FU being 2.2 follicles, this would put the average at around 50,000 FUs for a total of roughly 100,000 follicles.

 

The issue of donor becomes more confusing with the idea of an expanded donor for FUE. When Unger -- and a few others -- defined the "safe donor area (SDA)" years ago, they essentially based it off of someone with extreme NW VII balding, because everything in this area is truly "safe" if you assume the worst case scenario. Others have become more liberal with the model over the years (even in strip harvesting), but the latest data I've heard regarding available FUGs in the SDA is that Caucasians have around 10,000 with Asian and African hair types (fatter follicles) providing around 20-30% less.

 

HOWEVER, this data may be based upon strip harvesting. Many have argued that only 3% of patients truly ever progress to a NW VII, so it's safe "enough" to use a donor model that is expanded based upon someone who is more likely to end up in the NW V to VI category. This is especially true for FUE (I do it with mFUE as well) because there are areas in this expanded model that are considered "safe" but you obviously wouldn't want to try to access them with a strip harvest.

 

So what does this expand the donor to if you think about it in this model? Not sure. But I think most still assess the "thinning" factor based upon the original estimates. Meaning that if you're a Caucasian patient looking to do FUE, you could expect "thinning" if you went over the 5,000 graft level (50% of a 10,000 graft average) -- based on the original models.

 

Interesting food for thought though. Should the averages be reevaluated if we buy into the idea that only a small amount of patients will progress to a NW VII (IE where you really only have that strip to safely take from) and most will show obvious signs around age 30? Or are grafts taken from this expanded donor area still maybe a little "unsafe?"

 

Here's something from Dr Rassman about the donor capacity, just for reference:

 

"The entire head of a Caucasian has 50,000 follicular units. The donor area has at leas 10,000 follicular units, that means by harvesting with fUE half of the donor area, that means that a person would get 5,000 FUE grafts with a depleted, thin looking donor area. If the number was 15,000 rather than 10,000, then a person might get away for 7,600 follicular units for 7,500 FUE grafts. An Asian is 20% less and an African American is 40% less in terms of maximum yield of FUE grafts. It is not reasonable at the staft of this process to think beyond scalp grafts for FUE for many reasons, poor growth cycles, etc..."

[Melvin- Admin]

Hey HT,

 

Where did you read that the average non-AGA male has 100,000 follicular units (FUs)? The numbers I've always reviewed state that the average non-AGA male has about 100,000 follicles. With the average FU being 2.2 follicles, this would put the average at around 50,000 FUs for a total of roughly 100,000 follicles.

 

The issue of donor becomes more confusing with the idea of an expanded donor for FUE. When Unger -- and a few others -- defined the "safe donor area (SDA)" years ago, they essentially based it off of someone with extreme NW VII balding, because everything in this area is truly "safe" if you assume the worst case scenario. Others have become more liberal with the model over the years (even in strip harvesting), but the latest data I've heard regarding available FUGs in the SDA is that Caucasians have around 10,000 with Asian and African hair types (fatter follicles) providing around 20-30% less.

 

Here's something from Dr Rassman about the donor capacity, just for reference:

 

"The entire head of a Caucasian has 50,000 follicular units. The donor area has at leas 10,000 follicular units, that means by harvesting with fUE half of the donor area, that means that a person would get 5,000 FUE grafts with a depleted, thin looking donor area. If the number was 15,000 rather than 10,000, then a person might get away for 7,600 follicular units for 7,500 FUE grafts. An Asian is 20% less and an African American is 40% less in terms of maximum yield of FUE grafts. It is not reasonable at the staft of this process to think beyond scalp grafts for FUE for many reasons, poor growth cycles, etc..."

 

You are right blake i was confused hairs for FU's my mistake. However, i feel 5,000 to be an extremely conservative number. I myself have had 4,000 grafts extracted with another 2,000 to possibly 2,500 grafts availible according to a coalition physician who examined my donor microscopicaly.

 

Am i the outlier, i really dont think i am, according to my numbers i have an average of 1.7 hairs per FU, i would assume my average prior to surgery was 2.2 maybe less. I believe Dr. Rassman said that future hair loss could be predicted by age 27 according to miniaturization levels in the scalp. Assuming a patient is over 30 and has had their donor microscopicaly evaluated i think predicting the future is fairly good. Of course its not perfect and its good to plan for the worst but Norwood VII level of baldness remains the extreme rather than the norm.

 

I believe this numbers is a good rule of thumb to be conservative, but keep in mind there was a time when 1,500 grafts taken at once was considered a mega session. In my opinion the homogenization of the donor area imoroves the illusion of density to the top. Hair characteristics, donor density, extraction pattern, punch size and scarring physiology no doubt play a role in how many grafts can be extracted from a donor area. As long as the donor is homogeneous albeit thinner in my ooinion this actually helps the overall apperance.

[mahhong]

You are right blake i was confused hairs for FU's my mistake. However, i feel 5,000 to be an extremely conservative number. I myself have had 4,000 grafts extracted with another 2,000 to possibly 2,500 grafts availible according to a coalition physician who examined my donor microscopicaly.

 

Am i the outlier, i really dont think i am, according to my numbers i have an average of 1.7 hairs per FU, i would assume my average prior to surgery was 2.2 maybe less. I believe Dr. Rassman said that future hair loss could be predicted by age 27 according to miniaturization levels in the scalp. Assuming a patient is over 30 and has had their donor microscopicaly evaluated i think predicting the future is fairly good. Of course its not perfect and its good to plan for the worst but Norwood VII level of baldness remains the extreme rather than the norm.

 

I believe this numbers is a good rule of thumb to be conservative, but keep in mind there was a time when 1,500 grafts taken at once was considered a mega session. In my opinion the homogenization of the donor area imoroves the illusion of density to the top. Hair characteristics, donor density, extraction pattern, punch size and scarring physiology no doubt play a role in how many grafts can be extracted from a donor area. As long as the donor is homogeneous albeit thinner in my ooinion this actually helps the overall apperance.

 

In my experience I would say the average man's donor yield, via FUE, is usually around the 6 - 6.5k mark. I think to only get 5k would be fairly rare, but to get more than 7.5k isn't that common either. In most of the cases posted on here on reputable doctor's websites that contain the relevant information, a yield of about 6,000 - 6,500 grafts seems the most common.

 

I also think you bring up an interesting point about FUE being able to "spread" the hair more evenly from donor to recipient region, and in doing so balance out the overall density of their hair. I've heard a few doctors say this and it does have some merit. Going into what Dr. Bloxham said too, it might be that FUE opens up the donor area, and that going the FUE route gives the patient the option to "rebalance" their hair density across the scalp rather than simply removing a strip of hair and replacing it in the recipient site, leaving the remaining donor region at native density. I don't know if it would pan out that way, but it's interesting.

 

I also agree that true NW7 seems pretty rare, but one thing I do think we need to keep in mind is that the Norwood scale just approximates someone's balding to a visible pattern and is not a predictor or accurate indicator of balding. Two men may both be NW5 but one could have 140cm2 of area that needs to be transplanted into and the other 185cm2, depending on a variety of factors. I do believe the donor area in most men is slightly larger than the defined SDA, but it still varies widely from man to man even if they have ostensibly the same balding pattern. And of course the problem is you can't really undo mistakes in hair transplantation, at least not to the donor region. If you overharvest you may still have some options with body hair and micropigmentation but I think most men would feel pretty glum at the thought of having to fix their donor area!