One pass or two pass procedures

[Julius]

Hi there I was just Dr Hasson's profile on The Hair Transplant Network and he is apparently "recognized for his 'one pass approach' that achieves desired density for the patient in one procedure instead of two or three" to reduced scarring, although I was speaking to another coalition doctor who said that he uses the 'two pass approach' to achieve the exact same thing and also for a better yield. I was wondering if I could get some more opinions on whether it is better to take a one or two pass approach for high density hts in regards to yield and scarring? Cheers

[the B spot]

There is no real "best" way.

 

If you need a very large number of grafts (5000+), then your 1st session should be something 3000 grafts or more, if your donor and laxity can provide this.

 

There is something to be said for getting an extremely large session, it provides a greater cosmetic impact and can be cheaper from a cost perspective.

 

However, it is my observation and experience that most of us HT patients end up with at least 2 HT's to reach their goals.

 

In this vein, a patient needing 5000+ grafts can do a session of 3500, then come back for another 2000-3000 to reach their goals.

 

Again, there is no right way, but we all agree that for those needing a large amount of grafts, larger sessions are needed to accomplish goals.

 

Take Care,

Jason

[hair_care]

Well generally doing 2 procedures, one front and one back could be better. This would help you save on costs as well as reduce the risks associated with very large sessions.

[Jotronic]

The "one pass approach" you mention is often misunderstood.

 

This approach is not synonymous with super megasessions like those which we are known for. It has more to do with the area in need being addressed in one session as opposed to two or even three to get the desired density and/or coverage. Take Bobman for example. While he had two sessions to get the results he is known for he is a perfect example of the one pass result.

 

 

He was an Advanced NW6 patient with no prior surgical history. The approach was one pass of 4849 grafts. This established his hairline and the coverage for the top of his scalp. One session and no further work is needed.

 

 

The second surgery of 2955 grafts addressed the crown area.

 

 

Again, one surgery for the area in need with no need for more.

 

 

 

 

Another case would be that of Biscuit. He did not have as much loss as Bobman and so there was less work to perform.

 

 

4411 Grafts in one session by Dr. Wong allowed for a one pass result. Biscuit has good density and obviously good coverage.

 

 

Finally, there is this case which shows the one pass result achieved for the hairline.

 

 

2100 Grafts, eight months later, and the density desired is achieved and with no need for additional work.

 

 

 

 

If the ability is there as well as the need there is no reason why a one pass result should not be attempted. There is no issue with growth at higher densities as we simply have too many results to show otherwise. I think it is safe to say that most people understand that the more times you go into the donor area to harvest hair the more scarring one will have. The same goes for the recipient area as well. A single pass will also save the patient money, will reduce the downtime by at least half, and of course will allow for the final result in half the time.

 

"...although I was speaking to another coalition doctor who said that he uses the 'two pass approach' to achieve the exact same thing and also for a better yield."

 

I HIGHLY encourage this doctor to come forward and state his case online and to back up his claims with clear photographs. Many clinics make a lot of claims behind the scenes but it is something else to say them online publicly where they have to back it up. For this Dr. to say that his two pass result in one recipient area has a "higher" yield is a large claim because he either is saying that our one pass approach has sub-optimal growth or he is saying that his growth rate exceeds 97% to 100%. Either should be easily documented with dozens of results.

[thanatopsis_awry]

I agree w/ all the above. Unequivocally. If you prefer to go in for extra HT surgeries the choice is yours, and I suppose I could think of a reason or two why one might, but issues of yield and scarring truly shouldn't be in your equation; because they simply aren't in the equation.

 

It also cracks me just how often *anonymous* docs take swipes at H+W and the approach they've fostered; and it's always behind closed doors when they are trying to impress prospective patients.

 

To be blunt, I not only would encourage the doc to step forward and simply state his opinion out in the open, but I encourage Julius to simply say who it was, for the sake of basic transparency.

 

There shouldn't be a big mystery to this, or a cloak covering up a chosen few. If a doctor tells you something he better have said it because he actually believes in what he is telling you -- a patient for major surgery -- with all his heart. There is *zero* (good) reason why truly...truly...basic transparency should be sacrificed and fostered.

[Julius]

For the sake of transparency which is what this forum is all about it was Dr Brad Limmer; who is a coalition surgeon producing truly fantastic results with this approach. To put it into context it was in response to this post I made:

'In the past I have been told that a density of 50 grafts per cm2 should not compromise graft survival, though was wondering would transplanting at 55 grafts per cm2 or 65 grafts per cm2 compromise vascularity or hair growth yield? And if any graft survival is compromised at all leading up until natural density? Cheers.'

This was Dr Glen Charles, another great coalition surgeons' reply:

'I agree that the answer really depends on what clinic/doctor you go to. Some doctors have the capabilities of placing higher numbers of grafts in smaller spaces and still obtaining a high yield percentage. There have been a few recent studies showing very high success in the range of 90-100 FU's/cm. Here is an example of a common dilemma/question . Would you rather have 60 FU's/cm and get 50 FU's grow or have 45 FU's/cm and get 43 FU's grow. Most would choose the latter based on the percentages of successful yield. The bottom line is that there are countless variables that go into the equation, and it will always be a hard decision.'

 

And this was Dr Limmer's reply:

 

'Julius:

I agree with what has been said regarding percentage yield at various densities and Dr. Charles points out a most important point regarding this question,

'there are countless variable that go into this equation.'

Some are patient dependant and some are clinic/technique dependant, so the outcome can be different between patients even though they go to the same clinic.

 

We have typically approached the problem of yielding densities higher than 50 f.u./cm ?? by a 2 pass approach. While more conservative than some (who produce nice results), I feel it minimizes 3 important risks to the patient:

1. less than optimal growth

2. potential for ridging (dermal fibrosis below the skin ??“ which is basically scar tissue resulting from the multiple recipient sites create in such a small area)

3. permanent neovascularization (redness that won't go away ??“ resulting from capillary proliferation during the healing process)

 

Sorry for the diversion from your question, but the problem of lower yield can often be easily addressed. Ridging and redness can be permanent. Granted this is not always going to occur at high densities, but this had not been seen with f.u. micrografting until ultra high densities became more common. It was a problem seen years ago with plugs/minigrafting but is now occasionally being seen again. So while not an absolute contra indication, at least be aware of the possible risks.'

[Severn]

That's a good write up from Dr. Limmer.

 

It doesn't sound at all like they are taking a swipe at other clinics. Just sounds like they have a different approach. No different really than in any other field of medicine.

[Guest Brad Limmer, MD]

Severn:

 

Thank you for reading and realizing what I posted was not a swipe at any clinic, as Jotronic seems to imply. Techniques are always going to differ from clinic to clinic, but in the end your goal is to produce consistently excellent results for every patient.

 

The reasoning behind my approach is based upon a combination of science/data, personal experience (over 15 years) and the outcomes of my patients/other surgeons' patients. In the end there is always going to be risks associated with transplantation, I'm trying to manage/minimize the risks that concern me regarding a patient's surgery and final outcome.

 

Brad Limmer, MD/jac

[Julius]

I would love to get feedback on whether one dense packed session or two lower density sessions are better for overall survival?

 

The case for a 1 pass procedure:

 

Dr Tsilosani research:

The first se­ries of observations were held on two volunteers in 2003.Two-hair FU grafts were transplanted in 1cm2of bald scalp. For the creation of recipient sites, Nokor needles were used. Our research showed that tripling the densi­ty from 15 (in control sections) to 45 FUs per cm2did not reduce survival and achieved a survival rate of 99% and 107%, respective­ly.

 

Another study by Dr Tsilosani on two people, in the first one hun­dred FUs were insert­ed (70 two-hair and 30 one-hair grafts; 170 hair follicles in total) 156 out of 170 implanted hair fol­licles grew (survival rate of 92%). In the second 400 grafts were implanted into the recipient sites (200 two-hair and 200 one-hair grafts; 600 hair follicles in total) 574 out of 600 im­planted hair follicles grew (survival rate of 96%). However the recipient area was only 1cm2 in the first and 4cm2 in the second. Would it work over a larger area?

 

Also Dr Wong and Dr Nakatsui apparently have shown growth of 126 out of 130 implanted follicles in coronal recipient sites in 1cm2 (survival rate 96.92%).

In one study by them on examination of the most densely packed area (72 grafts/cm2) at 8 months post transplant revealed that the number of implanted grafts showing growth was 98.6% whereas the least densely transplanted area (23 grafts/cm2) revealed a growth rate of 95.6%.

 

 

Reasons why this approach may be best are because it may stop shock loss to pre-transplanted hair and damage to donor region; the more times you go into the donor area to harvest hair the more scarring one will have. The same goes for the recipient area as well.

 

Although what Emperor said caused me some concern:

 

“In my case, after #1 I noticed that some areas in the hairline seemed to have less grafts growing than internally (behind the hairline), despite originally being planted at higher density. My conclusion was that the front of the hairline was dense packed and didn’t get the hoped for yield. Most of the grafts behind the hairline seem to have grown”.

 

And I find it unusual in light of Dr Wong’s research that the Emperor could say:

 

“More than one reputable doctor has stated that if they dense pack, they run the risk that nothing will grow. I know Dr. Wong said this to me when we talked about my plans for #1”.

 

I do agree H&W have the results to support the case for a one pass approach but what is the best ultimately for survivability and thus results?

 

I heard one doctor say there is, a 'sweet spot' for dense-packing a large number of grafts into a small area without risking complications. Unfortunately, there is no magical number that works for everyone. The perfect graft density varies with the unique tissue characteristics of the patient at hand and it is profoundly influenced by the technical intricacies of the operating surgeon.

 

 

 

The case for a 2 pass procedure:

 

Mayer’s study of hair counts at eight months showing that a combined survival rate of 97.5% for grafts placed at 10/cm2, 92.5% for those at 20/cm2, 72.5% for those at 30/cm2 and 78.1% for those at 40/cm2.

 

Apparently Coalition member Dr. Ray Konior presented a case where a patient originally had 3000 grafts densely packed in the frontal third up to 100 FU/cm2. Considering natural hair density is typically around 80 FU/cm2, this hair transplant patient’s hair should have been so dense that nobody could see his scalp through his hair after his first surgery. Unfortunately, though 100 follicular units were packed per square cm, hair regrowth yield was significantly less leaving the appearance of hair loss and thinning hair.

 

And I found this on SMG’s website:

Placing grafts at densities up to 30-35 FU/CM2 will consistently produce survival rates of over 90 percent. Although successfully placing grafts at higher densities (40-50+ FU/CM2) is possible, studies show that as the transplanted density increases beyond 40, the potential for poor survival also increases. With appropriate patient selection and proper technique, this risk can be decreased but not eliminated.

 

This approach overcomes the primary concern of the one pass approach which relates to the risk of compromising the local blood supply within the recipient area. Reduced circulation decreases oxygen delivery to the recipient area. Vascular disruption can ultimately decrease graft survival, and when taken to an extreme it can cause outright tissue damage. So transplanting hair at such a densities in a one pass approach compromises vascularity and increases the risk of necrosis and “shock loss” to existing hairs.

 

A two pass approach also helps overcomes these dilemmas of the one pass approach:

1. Less than optimal growth

2. Potential for ridging (dermal fibrosis below the skin ??“ which is basically scar tissue resulting from the multiple recipient sites create in such a small area)

3. Permanent neovascularization (redness that won't go away ??“ resulting from capillary proliferation during the healing process)

 

Also most doctors in theory seem to advocate a two pass approach

 

 

 

 

 

Something of interest relating to all this is what Dr Feller has said “I've also notice that if a patient has a significant amount of bleeding during creation of recipient sites that the plan should be immediately changed to decrease the overall density”.

 

And the four reasons outlined by Dr Tsilosani for the reduction of graft survival, (if it really occurs):

 

1. “Lateral pressure” on the implanted grafts in very small recipient sites

2. “Ultra fine” preparation of grafts, leading to the absence of tissue around follicles, or artificial splitting of FUs with the purpose of enabling the their implantation into smaller sites

3. Crush injury of grafts when assistants push them into small recipient sites.

4. Violation of blood circulation in the recipient site by excessive incision density

[Megatron]

great post Julius. I too would enjoy learning more about this topic. I tend to trust what reputable doctors say based on their experience a little more than what some random study showed.

 

there are some very important topics / issues that haven't been fully explored / explained relating to HTs and this is definitely one of them.

Edited May 28, 2010 by Megatron

[Julius]

It would be great if hair restoration surgeons could contribute by giving their personal views based on experience as to whether one dense packed session or two lower density sessions are better for overall survival.

 

I would particularly like to hear from Dr Wong (who I think is a brilliant surgeon) so he can clarify what he said to Emperor.

[TheEmperor]

Julius,

Dr. Wong said just what I said he did, but you should probably call them and report back here, rather than trying to bait an altercation.

 

I believe that Wong is conservative in his approach. He expressed that if you dense pack too much, there is risk of nothing growing. Ultimately, when it came time for the procedure, I left the question of density to his judgement.

 

Regarding "one pass procedure", I though I was going to have something closer to Bobman's result. Obviously results vary. Even if all of the grafts had grown, I would probably have still required a second pass. I think the goal is to get an area done in one pass, but I am evidence that this approach does not always pan out. Not saying that H&W are bad or negligent, only that things do not always work out as planned.

 

The question of yield vs density is a very good one to ask.

 

My opinion is that they plant at a relatively high density. If everything grows, they get a home run. If everything doesnt grow, or if hair quality is poor, they go back for a second pass. If they didnt attempt a one pass procedure, then patient would be guaranteed to have two procedures, so it is a calculated risk. If they dont go crazy with dense packing, then a good percentage will grow, so even if (say) 500 grafts dont grow, that will not destroy the patients prospects overall.

 

You should also ask why people only have typically 7K grafts in the bank. This was not apparent to me before the surgeries. ( It is interesting what removing 2-3cm of skin does to the rest of the scalp. You will only know once youve had procedures.)

 

Another question you should ask is why patients often report reduced yield in 2nd, 3rd procedures. As I watch my #2 grow out, it is curious that the areas that had poor yield before are showing delayed/less growth now. I can only assume it has something to do with the hidden scar tissue that SMG mentioned.

 

Another question you should ask is about graft size. Looking through results you will see many of the most impressive results are repair patients who had minis or larger FUs. Larger FUs create more scarring (larger incisions), but contain more hairs. If there is a ratio of scarring to hairs, the larger grafts are superior.

 

Also, chubby grafts require larger incisions, but have shown greater yield. Skinny grafts create less scarring/smaller incisions and can be placed closer together.

 

Also ask whether the quality (thickness) of transplanted hairs can be influenced by cutting techniques. I have read that grafts which are damaged in cutting will often grown but at a finer caliber. I suspect chubby grafts receive less trauma.

 

I signed up for Dr. Wong's approach to HT based on the "one pass approach" and large graft counts, but given that I needed two passes anyway, I think I would have gotten a better result going to a clinic that uses chubby grafts, and/or double FUs with medium session sizes. I truly belive that 3000+3000 is going to be better than 6000 or 4500+1500. (of course, after only getting 3000, you will not be close to finished, so getting a very large first procedure will get you closer to your destination, so sacrificing yield for faster results is probably in most peoples best interest.) Smaller session sizes afford the doctor more freedom in choosing better hair, and he can respond to the results of prior procedures better.

 

You will see a trend that often guys who have say 3-4 medium-small sessions get more density than the guys who try to get it in 1-2 megas. That does not speak the naturalness. I think the skinny graft+megasession provides more natural results, but potentially compromises yield and hair quality.

 

Julius, keep doing you research and listen to what various doctors say. There is NOT one right approach.

Edited May 30, 2010 by TheEmperor

[Julius]

Mate, I was not trying to bate an altercation, I just said I think he is a brilliant surgeon!

 

I actually thought it was a good time to bring it up after reading your posts in Phil Mascallpen’s thread where you seem to write off a one pass approach and imply that dense packing was the ‘culprit’ for less yield.

 

All I am hoping for is that the good Dr can explain why he said that to you in light of his research.

 

Can you please try to explain what removing 2-3cm of skin does to the rest of the scalp?

 

Good point Emperor about many having reduced yield in 2nd, 3rd etc procedures maybe this strengthens the case for a one pass approach, it would be great if a Dr could explain why this happens (if it does at all)?

 

I once read something on minis and how when combined with fut that the transplant appears denser, although the study came to the conclusion that the same appearance of density could be created with futs alone.

Edited May 30, 2010 by Julius
Error

[TheEmperor]

Please direct your questions to the doctors. I am just repeating what I have been told or discovered reading thousands of posts.

[Fingers Crossed]

Emperor...you don't have to answer this if you don't want to but I was wondering if H&W charged you for the second procedure you received? Any discount? I know you were not too thrilled with the yield of the first procedure, but after viewing your hair loss website, I think you'll be very pleased with the outcome of this procedure. Best of luck

[TheEmperor]

You guys some advice:

 

If you have a specific question for a specific doctor, contact the doctor directly. If you have questions about how much another member paid for his procedure, contact the member directly.

 

Airing personal questions publicly is bad form.

[Megatron]

TheEmperor raises a lot of great questions in his post above.

[mmhce]

Good post!