How Many Grafts are "Needed" in a Transpalnt

[Dr. Paul Shapiro]

How Many Grafts Are 'Needed' For a Hair Transplant Surgery?

 

Recently Jana posted photographs of my patient Brad Becker:

http://hair-restoration-info.c...21087683/m/918102092

This post elicited a common response that we get when we post a Shapiro Medical Group patient on the HTN web site. The response usually states how good the case looks considering the small number of grafts we use.

Here are a few recent quotes on the HTN about SMG patients:

 

'This is great result for only 2500 grafts'

http://hair-restoration-info.c...=104101501#104101501

 

'Amazing coverage for the number of grafts Janna.'

http://hair-restoration-info.c...21087683/m/606101362

 

 

'janna,a very pleasing result with relatively few grafts(considering the area covered)'

http://hair-restoration-info.c...21087683/m/158100281

 

'Wow, Janna! Those results for the # of grafts are amazing, they really are'

http://hair-restoration-info.c...051020473#7051020473

 

 

These comments suggest that there may be a misconception on the number of grafts needed to accomplish a patient's hair transplant goals. I like to think that we use the appropriate amount of grafts for each case taking into consideration the patients goals, donor density, hair caliber, age, degree of balding, family history, response to medical treatment, and the risk/benefit ratio as the cases get larger and go longer.

I would like to point out a few reasons why surgeries using less grafts may lead to the same or very similar results to transplants using greater number of grafts.

1) Each patient has a threshold level of hair density in which their hair will look full under most conditions. Once this threshold is reached as we increase the hair density we get only minimal esthetic improvement. For example let's say a certain patient needs 2,000 FU to reach this threshold level for the area being transplanted. If we transplant 2,500 FU in this area the esthetic improvement will be very similar to planting 2,000 FU. Thus the results of the two transplants could look similar even though in one surgery 500 more FU were planted.

2) We often are transplanting into areas in which there is existing hair in the early stages of thinning. In most of these cases I need to plant 20 to 30 FU/sqcm in these areas to get an excellent cosmetic look. With proper magnification I can plant 30 to 40 FUsqcm in these areas but usually chose not to. I find that in most cases these extra grafts do not yield a significant denser look. Some argue that if we can plant more hair in an area then why don't we do it as a preventative measure. The possible advantage of this preventative philosophy is that as a patient loses his native hair he still has more transplanted hair and will not need another hair transplant? The disadvantage of dense packing in areas of pre-existing hair is that there is an increased risk of transection and shock loss which could damage existing hair. I am not sure the advantage outweighs the disadvantages of this preventative philosophy. Especially because in my experience if a patient does have progressive hair loss they will still want another transplant to achieve their goals and we will not have saved them another hair transplant.

 

3) All patients have a different percentage of 1,2,3,and 4 hair FU's. There are studies which show that the number of 4 hair FUs can vary from 5% to 20% of the total graft count. It is difficult to compare surgeries without knowing the exact number of 1,2,3, and 4 hair FUs which allows us to calculate the number of hairs transplanted.

There is some discretion when cutting FUs. The photo below is a close up of a patient's donor hair. The area circled in Black is a 3 hair FU that could not be split. But as you can see the area circled in Red can be cut many ways.

 

At SMG we do believe that the larger 4 and 3 hair FUs give a greater illusion of density in the central core area and thus try to get as many 3 and 4 hair FU unless we are doing a hairline case or the patient has coarse dark hair. There is the possibility that our results look similar to some of the larger cases one sees on the internet because even though we are transplanting less total grafts we are transplanting more hair per graft. Also, by placing the maximum amount of 3 and 4 hair FUs in the central core area we believe we get a greater illusion of density even if we are using the exact same number of total hairs without compromising the naturalness.

 

If we can achieve the same cosmetic results using fewer grafts I believe there are some potential benefits to the patient. Here are some advantages I can think of:

1) Never lose sight of the basic principle of hair transplant surgery that we are using a limited donor supply to cover a potentially expanding balding area of the scalp. If we can get the same or similar results using fewer grafts, we have more grafts left over for future hair transplants if needed.

2) We strive to get the best graft survival when doing a hair transplant surgery. To maximize graft survival we protect them from dehydration by placing them in physiologic holding solution on ice, use tiny micro blades to limit the amount of vascular trauma to the scalp, and use gentle placing techniques. Most published studies show that even under ideal conditions we do not get 100% graft survival. I still have concerns about surgeries in which the grafts are out of the body for greater then 6 hours. Graft survival decreases the longer the grafts are out of the body. The most commonly sited study shows that after 4 hours graft survival decreases to 95%, after 6 hours graft survival decreases to 90%, and then graft survival continues to decrease by 2% for every additional hour they are out of the body. Also, as the cases go longer there is the possibility of staff fatigue resulting in less careful graft cutting and placing which could decrease graft survival. Taking into consideration that there is the potential for less graft survival as the cases become larger and go longer, I believe there is an advantage to keeping surgeries to the size where the placing can be completed within 4 to 6 hours.

A point I would like to make about graft survival is that we can not accurately measure graft survival in the clinical setting. The published studies on graft survival are done on completely bald scalp, in one centimeter square boxes that are tattooed onto the scalp, and the hair is planted as soon as it is cut. Even in these studies we usually do not get 100% graft survival. The graft survival ranges from 90% to 100%. Taking these studies into consideration no clinic can say they get 100% graft survival. My educated guess is that most good clinics get about 95% graft survival.

In general we judge our hair transplant results by the way the outcome looks. Since in clinical practice we can't accurately measure graft survival, as the sessions get larger we need to decide when the potential risk for decrease graft survival outweighs the benefit of a large session. Here is a hypothetical example to point out the potential risk. Let's say 4,000 and 5,000 grafts are planted in the exact same area. Now let's say the 4,000 transplant yields 95% graft survival and the 5,000 graft transplant yields 85% graft survival. That leaves us 3,800 and 4,200 grafts respectively. The 5,000 graft transplant will still look better then the 4,000 graft transplant even though there is less graft survival. I am not saying this is what happens, but since we can not accurately measure graft survival in our clinical practice the doctor and patient need to decide when this potential risk outweighs the benefits of a large megassesion.

3) Another advantage of keeping the surgery as short as possible is that there is decrease risk of medical side effects. Most patients tolerate the surgery fine, but there are some patients who get nausea, irretraceable hiccups, back /neck pain, or difficulty in keeping the surgical area numb. In my experience I find these side effects are more common during long surgeries. When a patient has these side effects it makes the planting more difficult and can affect graft survival.

4) As the surgeries increase in time, there is the possibility of Deep Vein Thrombosis (DVT). DVT is blood clot in the deep veins in the leg. Prolonged immobilization is one of the risk factors for DVT. A study showed that travelers who are greater then 50 years old have a 10% chance of developing asymptomatic DVT's on airplane flights that last longer then 8 hours. Lancet May 12,2001;357:1485-9 These asymptomatic DVT's usually do not cause any medical problems. But very rarely they can lead to a blood clot in the lung called a Pulmonary Embolism, which is a medical emergency and needs hospitalization. I had such an occurrence on a 45 year old male whose surgery lasted over 8 hours. (I published this case in the Hair Transplant Forum International) Like I said this is a very rare occurrence, but the possibility increases as we increase the length of surgery. When does this risk of DVT outweigh the cosmetic benefits of a prolonged cosmetic surgery?

At Shapiro Medical Group we do have general guidelines for the number of grafts we will transplant into different areas of the scalp. The guidelines are printed in the table below. These general guidelines are good for the average patient but sometimes our sessions will go larger and sometimes smaller then in these guidelines.

 

 

In summary, how many grafts are needed to get excellent results varies for each patient depending on many factors. But I do believe that if we can get the same or similar results using less grafts there are some advantages. We have less chance of using up limited donor supply that may be needed in future surgeries, potentially increase our graft survival, and limit potential medical risk as much as possible.

Paul Shapiro, MD

[TC17]

OUTSTANDING write up Dr. Shaprio, thank you.

[Petchski]

Yep, nice post Doc, very useful info

[PLEASE GROW PLEASE]

Thanks for taking the time to educate. Its extremely helpful

[mmhce]

Thank you for the article Dr. Shapiro!

 

Just a point out: I think there is a typographical error in that "HAILINE" should be "HAIRLINE" and, under Hairline "With hair" should be FU 0-800 and not 0-8000.

 

Please correct me if I am wrong.

[Dr. Paul Shapiro]

mmhc

I am glad you enjoyed the post

Thanks for pointing out the typographical errors.

I will change them

Dr. Paul

[TC17]

Dr. Shapiro,

 

I do have one question regarding your chart. While I recognize that there are a number of variables and that the chart is only a guide, I see that in the front 2/3rd you have listed 3,000-4,000 grafts as appropriate for when the patient has little to no hair. Extending that further, would you say that 6,000-7,000 would be enough to provide a cosmetically pleasing result over the entire scalp, the full 3/3?

[bash77]

Brilliant stuff - cheers Dr Shapiro.

 

Do the survival rates listed above (i.e. 95% - under 4 hours) apply to both FUT and FUE?

 

At SMG, could a patient have a total 8 hour session split over 2 days to maximise yield. If so, would this cost any more?

 

I probably need somewhere between 1600-2000 grafts and would be interested to know how long this would take via both methods? Again, great write up - many thanks!

[Dr. Paul Shapiro]

Originally posted by TC17:

Dr. Shapiro,

 

I do have one question regarding your chart. While I recognize that there are a number of variables and that the chart is only a guide, I see that in the front 2/3rd you have listed 3,000-4,000 grafts as appropriate for when the patient has little to no hair. Extending that further, would you say that 6,000-7,000 would be enough to provide a cosmetically pleasing result over the entire scalp, the full 3/3?

 

The question you ask is a good one. And as you pointed out there are many variables that may make the results different for each patient. Taking that into consideration I would say that in the 'average patient' using 6,000 to 7,000 grafts we can achieve a cosmetically pleasing result over the entire scalp. In the average Norwood type 5 or 6 the amount of total scalp needed to be covered is about 200 sq.cm. With 6,000 grafts we can recreate a mature hairline, create good density in the central core and get good coverage of the crown. In many patients the area of bald crown is so large that our goal is to shrink the crown but not completely cover the crown. This gives a cosmetically pleasing result because the hair in the upper crown falls down over the rest of the crown and the crown no longer looks bald. I also find that a lot of my patients in their second surgery decide to bring the hairline and temporal corners down a bit and chose not to have as much density in the crown.

 

Here is an example of an 'average' patient who had a total of 5,797 Grafts to cover his top and crown.

 

 

A patient of mine, Baxter, recently posted his results from his 6 month follow after his second surgery:

http://hair-restoration-info.c...=588102092#588102092

 

He is a good example of a patient with a large surface area to cover and a large crown. He had a total of 6,076 grafts and I covered about 250 sq.cm of scalp. The photos of the second surgery are only 6 months out and I expect to see more crown coverage at his one year follow up, but this should give you a feeling of what can be accomplished using 6000 grafts in a patient with a large surface area to cover. In Baxter's case I used 400 DFU's in his central core and each DFU is like two FU's so this case is the equivalent of a 6400 FU case.

 

I hope this answer is helpful

DR. Paul Shapiro

[Dr. Paul Shapiro]

Originally posted by bash77:

Brilliant stuff - cheers Dr Shapiro.

 

Do the survival rates listed above (i.e. 95% - under 4 hours) apply to both FUT and FUE?

 

At SMG, could a patient have a total 8 hour session split over 2 days to maximise yield. If so, would this cost any more?

 

I probably need somewhere between 1600-2000 grafts and would be interested to know how long this would take via both methods? Again, great write up - many thanks!

The survival studies I mentioned have only been done on the strip method. I think it would be useful to do some survival studies on FUE cases. When we extract the follicles by the FUE method they do not have as much tissue around them and to me they do seem more fragile then the grafts from the strip method. Thus I think it is wise to keep the cases smaller when doing FUE to ensure good graft survival.

 

If a patient has little or no hair, using the strip method, we usually can finish a 3,500 to 4,000 case covering the front 2/3's within 8 hrs. If the patient has hair and chooses not to cut it short, then the number of grafts we plant will be less. We have not done a strip case over two days because if we get a yield of 4,000 we can usually finish the case within 8 hours. If a patient came in who was a type 6 or 7 and had a great donor we might consider doing a 5,000 to 6,000 case over 2 days but that has never come up. If that happened I am not sure how we would do the pricing.

 

So far the largest FUE case we have done is 2,000 over 3 days (we probably could have finished that case in 2 days). Most of our FUE cases have been in the 1,500 range and it was over 2 days. Each patient is different but we can extract 800 to 1,000 follicles in a day using the FUE method. We want to see how these cases grow out before trying larger cases. I have seen some FUE cases where to get large number of hairs it looks like the doctors are going outside the safe donor area. As long as the patient knows that there is a risk that hair may not be permanent then that is ok. Also I have not seen many FUE cases over 2,000 where the results have been very good.

 

When doing a FUE case we charge the same regardless of how many days the case takes.

 

I hope this answer is helpful

 

Dr. Paul Shapiro

[bash77]

Questions all answered. Thank you Dr Shapiro for taking the time to respond. Much appreciated!

[TC17]

Thank you Dr. Shapiro. I too appreciate you taking the time to respond. This post is certainly one of the most informative that I have read on this site.

[Godzluv69]

I agree completely. l never thought of Dr. Shapiro. He was never on my list of Doctors under consideration, but this write-up is an eye opener. This is in contrast to Jontronic claim why Hasson & Wong is a better choice.(the post is somewhere on this board)

l recall his point was if you do a megasession there is no need to return immediatly and in most cases, that would be sufficient for most patients. He also added Hasson & Wong is attractive to most patient because their process eliminate going through the circle of down-time and the entire recovery regiment. He claimed those doctors that criticized their approach most probably lack the expertise and resources to accomplish this remarkable process.

l had plan to buy my ticket to Seattle next week(airtran is on sale) and rent a car from there upward to Vancouver BC to H&W. After reading this Dr. Shapiro write-up, l am having a second thought.

Great write-up Dr. Shapiro and l wish Jontronic or any Hasson & Wong associate would respond to this view, so prospective hair transplant patients we make an informed decision.

[HairDew]

Godzlov69,

 

I don't think you will see any other doctor commenting. I've never seen doctors on this side disagreeing with one another.

 

I hold GREAT respect for both SMG and H&W....because I judge them both by RESULTS. And they speak for themselves. There could be other factors that are in play with H&W. For example they might be taking the strip out in sections, thus preventing the grafts being out of body for too long, or they have many techs working on the strip once it's out. But at least I haven't seen bad results with H&W and their megasessions.

 

Just my $0.02

[Samsri]

Hi,

 

I am attaching my photos, how many grafts do you think I will need so that my appearance changes. I wish to have hair in front

[Dr. Paul Shapiro]

Samsri

You are a Nrowood type 6 going onto a type 7. Without knowing your age and if you are on medical treatment it is difficult to give you an exact number. But I would estimate you would have a session of 3,000 to 4,000 hairs and that would only cover the front half to the front two thirds to the top of the crown. You do have loss in the lateral hump areas and some hair needs to be used to build that up. You hair looks coarse and dense. Usually that means your donor density has less FU/sqcm then the average patient. But one of your hairs has more volume then someone with fine thin hair. In cases like yours the amount of FU we can get from the donor area is less than sometimes expected but the volume transplanted is more then expected.

Most clinics, including ours will do consults without a charge. If you are interested in more detailed consult please call our office.

I hope this is helpful

Dr. Paul

[Samsri]

Thank You Doctor, I appreciate your time and efforts for this analysis. I am 40 years and am diabetic. Cost is also a concern and I was thinking about 2500 grafts.