Extracting grafts from only one side of the head - can anyone explain the benefit?

[giegnosiganoe]

Saw this mentioned in another thread and thought it deserved its own thread.

I've never heard of a good reason for extracting from only one side of the head (assuming the donor density is fairly symmetrical along the horizontal plane).

There are two things I can think of that matter in this discussion: 1) the health of the remaining grafts, and 2) spreading out extractions to limit the difference in density across the donor. For the first point, I don't see how it makes a difference - a good surgeon should be able to extract quality grafts from anywhere in the donor region without affecting the neighboring grafts. If they can safely extract from one side of the head, why wouldn't they be able to do so for the other side of the head, especially when they have more space between extractions? For the second point, extracting evenly across the entire donor area obviously wins according to basic math. So according to these criteria, extracting from only one side of the head is strictly worse.

Can anyone explain what they think is the benefit of extracting from only one side of the head? Leaving one side of the donor "virgin" is what you commonly hear as a defense. I guess it sounds compelling because people usually leave the discussion at that from what I've seen, but I really don't see how that means anything in and of itself.

[Gatsby]

I have also seen this @giegnosiganoe. I have always thought that it is to ensure their are enough grafts for work in the future or it is part of a two stage approach to address the hair loss surgically.

[Al - Moderator]

If you use the entire donor area on the first hair transplant, you have hairs missing from all over. Now you go for a second transplant and it gets much harder for the Dr to properly space out all the grafts without taking some from directly next to (or above or below) where another graft was taken earlier which could create small spots with no hair and look moth-eaten/depleted in those spots. Using one half of the head first allows the Dr to use a full, untouched area on the second transplant and thus reducing the chance of it looking depleted. It also can be easier to extract grafts from an unscarred area rather than from an area where grafts were already taken because there can be some scarring underneath the skin from pulling the grafts out. That scarring can be a lot wider than the small dot punch mark on the surface. I'm not saying this should always be done. I'm just trying to give you the answer you seek.

 

 

Edited October 15, 2021 by BeHappy

[Curious25]

It’s pretty logical - the larger the surface area of the donor you can keep Virgin, the easier it is for surgeons in future surgery’s to execute new extraction patterns from. It also mitigates risk - carrying out as much damage limitation as possible throughout every step of the surgery is best practice. 

Like I said in the other thread , anything less than 2000 grafts in a candidate with a good donor, won’t make a visual difference at all from only one side of the donor being extracted from. 

[giegnosiganoe]

6 hours ago, Gatsby said:

I have also seen this @giegnosiganoe. I have always thought that it is to ensure their are enough grafts for work in the future or it is part of a two stage approach to address the hair loss surgically.

The number of remaining grafts in the donor should be the same for either approach though.

6 hours ago, BeHappy said:

If you use the entire donor area on the first hair transplant, you have hairs missing from all over. Now you go for a second transplant and it gets much harder for the Dr to properly space out all the grafts without taking some from directly next to (or above or below) where another graft was taken earlier which could create small spots with no hair and look moth-eaten/depleted in those spots. Using one half of the head first allows the Dr to use a full, untouched area on the second transplant and thus reducing the chance of it looking depleted. It also can be easier to extract grafts from an unscarred area rather than from an area where grafts were already taken because there can be some scarring underneath the skin from pulling the grafts out. That scarring can be a lot wider than the small dot punch mark on the surface. I'm not saying this should always be done. I'm just trying to give you the answer you seek.

But if you extract over the entire donor vs just half, then you should have 2x as much space between extractions, so it shouldn't be that difficult to space it out if you have to do a next procedure? And I never see this method done with people who actually need multiple procedures - it's always those with minimal loss (which makes sense since it's difficult to extract 3000+ grafts from only one side of the head). Take someone like Dr. Zarev, who pushes the donor to the absolute limit. Not even he has an issue extracting evenly across the donor over multiple surgeries. It surely takes more planning/effort, but he seems to be proof that it can be done without any disadvantage.

And I'm not sure I buy the scarring argument. Is it that the scarring of an extraction somehow affects the neighboring grafts? What does it do to them exactly? You'd also have 2x as much space between extractions, so it would be unlikely for the grafts you'd extract the 2nd time around to be affected assuming that were a problem.

5 hours ago, Curious25 said:

It’s pretty logical - the larger the surface area of the donor you can keep Virgin, the easier it is for surgeons in future surgery’s to execute new extraction patterns from. It also mitigates risk - carrying out as much damage limitation as possible throughout every step of the surgery is best practice. 

Like I said in the other thread , anything less than 2000 grafts in a candidate with a good donor, won’t make a visual difference at all from only one side of the donor being extracted from. 

I responded to some of this in my comment above.

How are you quantifying "damage" here? The number of extractions/surface area of scarring doesn't change whether you extract over the entire donor vs only half. I'd argue that placing the extractions closer together increases risk, as it would seem more difficult for the body to heal from wounds spaced closer together.

I get that 2000 grafts may not make a noticeable difference in most cases (I've seen docs who do this go up to 2500). But I do think a more even extraction pattern would allow a slightly shorter cut on the back/sides. And what if we think about longer term if the patient continues to lose density in the donor, even simply due to senile alopecia? At some point that difference may become visible.

[JDEE0]

I also always thought it was kind of strange, but I know doctors such as Bisanga etc. use this approach sometimes and so I never really questioned it.

I also don't think it's due to being able to continually extract evenly over multiple surgeries either, at all, as this is very much the norm and works due to simple maths. Lets say your lifetime donor supply is 7000 (and stays pretty steady at this number), this essentially means that once 7000 are extracted - and it's going to have to be across the whole viable donor zone in the end anyway for calculation to work in the first place - then you're at say 30 percent overall depletion and any more risks over-harvesting and so you stop there. So whether you end up incrementally reducing the total donor availability homogeneously over concurrent surgeries, or you do it half by half, I don't see any difference in the end as you're essentially just extracting x amount of grafts per cm2 of the donor zone at the end of the day. 

From everything I've heard, it's just because the doctor likes to work on virgin scalp where possible as they think it's easier, find the scalp to be overall healthier, and so on. I don't think it's a case of 'this way is superior to homogeneously extracting' but more, 'if it's a case where we can do it, then why not', especially if the surgeon overall believes virgin scalp to be somewhat more viable, even if by just a tiny amount. I suppose the argument here would be that this side of the scalp has not been scarred and so the blood supply hasn't been interrupted at all on this side; maybe *some* grafts take a slight hit due to FUE and lose some level of quality, I really don't know. I'm more just speculating/playing devils advocate to be honest as I don't think it really makes any difference at the end of the day either. 

The only thing I don't like about it is that it leaves someone with an obvious pattern of scarring on their head, what if they never go back in for round 2 and shave in 30 years time, or just like to wear their hair short on the sides regardless of some slight FUE scarring? Our eyes are drawn to these things and it will stand out like a sore thumb whereas it can be fairly undetectable if they were just spread out in a random, scattered pattern with no clear 'edges' or basically a border around them. 

[Melvin- Admin]

2 minutes ago, JDEE0 said:

I also always thought it was kind of strange, but I know doctors such as Bisanga etc. use this approach sometimes and so I never really questioned it.

I also don't think it's due to being able to continually extract evenly over multiple surgeries either, at all, as this is very much the norm and works due to simple maths. Lets say your lifetime donor supply is 7000 (and stays pretty steady at this number), this essentially means that once 7000 are extracted - and it's going to have to be across the whole viable donor zone in the end anyway for calculation to work in the first place - then you're at say 30 percent overall depletion and any more risks over-harvesting and so you stop there. So whether you end up incrementally reducing the total donor availability homogeneously over concurrent surgeries, or you do it half by half, I don't see any difference in the end as you're essentially just extracting x amount of grafts per cm2 of the donor zone at the end of the day. 

From everything I've heard, it's just because the doctor likes to work on virgin scalp where possible as they think it's easier, find the scalp to be overall healthier, and so on. I don't think it's a case of 'this way is superior to homogeneously extracting' but more, 'if it's a case where we can do it, then why not', especially if the surgeon overall believes virgin scalp to be somewhat more viable, even if by just a tiny amount. I suppose the argument here would be that this side of the scalp has not been scarred and so the blood supply hasn't been interrupted at all on this side; maybe *some* grafts take a slight hit due to FUE and lose some level of quality, I really don't know. I'm more just speculating/playing devils advocate to be honest as I don't think it really makes any difference at the end of the day either. 

The only thing I don't like about it is that it leaves someone with an obvious pattern of scarring on their head, what if they never go back in for round 2 and shave in 30 years time, or just like to wear their hair short on the sides regardless of some slight FUE scarring? Our eyes are drawn to these things and it will stand out like a sore thumb whereas it can be fairly undetectable if they were just spread out in a random, scattered pattern with no clear 'edges' or basically a border around them. 

I will use the analogy Dr. Konior gave me, suppose you go the grocery store right when it opens to get fresh tomatoes, you have the freshest brightest tomatoes right at the front. Ripe for the picking.

Now, suppose you return a few days later, to get more tomatoes, most of the ripest tomatoes will be gone. The left over tomatoes won't look as fresh and bright, they'll look more like this

Getting multiple FUE's is a lot like that, each time the doctor performs an FUE, he's picking the best grafts, the healthiest most robust grafts, and each time he returns, there is less, and less, and less. Now, imagine the grocery store only allowed customers to pick from one side of the tomatoes, when you return a few days later, there's still gonna be some good ripe tomatoes to pick from. 

FUE causes a lot of damage, more than FUT. If you were to take all of the sub-dermal scar tissue from having thousands and thousands of holes punched out of your head, and compared it to a linear strip, you'd be shocked at how much more damage you accrue from FUE. That is why for so many years FUT was touted as the best procedure, that is also why it is suggested to go FUT first before FUE, so you have sections of your donor (virgin) untouched. It really is common sense. 

[JDEE0]

20 minutes ago, Melvin- Moderator said:

I will use the analogy Dr. Konior gave me, suppose you go the grocery store right when it opens to get fresh tomatoes, you have the freshest brightest tomatoes right at the front. Ripe for the picking.

Now, suppose you return a few days later, to get more tomatoes, most of the ripest tomatoes will be gone. The left over tomatoes won't look as fresh and bright, they'll look more like this

Getting multiple FUE's is a lot like that, each time the doctor performs an FUE, he's picking the best grafts, the healthiest most robust grafts, and each time he returns, there is less, and less, and less. Now, imagine the grocery store only allowed customers to pick from one side of the tomatoes, when you return a few days later, there's still gonna be some good ripe tomatoes to pick from. 

FUE causes a lot of damage, more than FUT. If you were to take all of the sub-dermal scar tissue from having thousands and thousands of holes punched out of your head, and compared it to a linear strip, you'd be shocked at how much more damage you accrue from FUE. That is why for so many years FUT was touted as the best procedure, that is also why it is suggested to go FUT first before FUE, so you have sections of your donor (virgin) untouched. It really is common sense. 

Yeah, I do understand the sentiment behind the analogy, but my point is: what difference does it make if you pick all the healthiest most robust grafts from one side of the scalp, leaving the other side ripe for the taking for next time, or take half of all the healthy robust grafts from the whole donor, leaving the other half ripe for the taking for next time? Whether or not you pick from one side or not, the total amount of ripe tomatoes, or robust grafts, across the whole donor is still the same in the end isn't it. It's not as if by harvesting one side you get any more; if there are lets say 3000 extremely robust grafts in your donor and you take 1500 from one half, leaving it with none left but the other side still with 1500, what difference does it make to take 1500 from the whole donor, still leaving 1500 over for next time.

I agree with the second point more though in that this is what makes the most sense to me, as I alluded to in my previous comment on this thread, and it could also potentially answer my points of contention above somewhat.

I imagine the scarring and potential constriction of blood flow to the surrounding grafts of those harvested could potentially have some affect on their healthiness or robustness. I can't see it being a huge issue as, well, lots of amazing surgeons don't use this technique at all and I'm sure it would be commonplace if it was truly an issue, but maybe some grafts do shrink a little bit here and there, in a way similar to how those above and below FUT scars do, and so going at one side a time where possible can mitigate this issue by allowing a surgeon to grab those 1500 grafts without compromising at least any more of the robust grafts as they've all been taken.

[1978matt]

I think taking grafts from one side depends on a few factors, namely the session size and the quality of the donor.

For example, if you need 1000-1500 from an outstanding donor area, taking it from one side leaves no noticeable change in density.  The advantages from a surgical perspective are that you don't have to keep moving the patient around, and also numb down a smaller area of scalp.  I'm no doctor but clearly this saves time and reduces risks to a certain extent.

Say someone had a slighly below average donor and you wanted to get 2500 grafts.  Cleary it would be better to spread things out than create an abnormally thin side sompared to the others.

I guess you can apply the same idea to FUT.  If you just need 500 grafts, you wouldnt go and make a 30cm scar.  You just do 10cm on one side, minimising risks of stretching, bleeding etc.

[Briguy]

Another point to consider is who's extracting the grafts?

A Doctor or a Tech doing the extractions like what happens in the majority of clinics.

How skilled and experienced is that tech in doing the extractions. I know from my experience having my surgeries at H&W I had a very highly skilled tech but they extract from over the full donor. 

I'm assuming the clinics were talking about here that extract from only one side are being performed by the Doctor.

Any one know of any clinics where a tech is performing extractions from only one side of the donor?