Two ways to do high NWs. Pros and Cons?

[Xanadu]

Usually we have seen a two-step procedure (Type 1) with first the front (and perhaps midscalp), and then a separate procedure for the crown.

Recently, however, I have seen clinics do another kind (Type 2) of two-step procedure. First the front is packed well, the midscalp and crown with limited density, and then in a second procedure the midscalp and especially crown are filled in.

I am seeing examples where a similar amount of grafts are used in the first session (around 4000) and second session. Just how they are used is different.

...

I can think of a pro of Type 2 which is that the whole scalp is covered to some degree despite not good density. I guess that would make the period up until the second step a bit more enjoyable?

In terms of cons, I wondered if it was easier to start with a blank slate for crown, rather than have to pack in density? If so, then that might be the reason for Type 1?

 

Edited November 1, 2022 by Xanadu

[mister_25]

The pro of type 2 would be that you can use fibers to get a strong illusion until your second surgery where you wont need them anymore.

 

[Curious25]

One of the main advantages with a more conservative initial intervention, is for analysis of how the patient takes to surgery, and what his growth rate was. 
 

Aside from that, Surgeries with a smaller number of grafts leads for a higher likelihood of achieving a high graft survival rate, less chance of trauma and transection to the donor, and a better look at the landscape for surgery number 2/3/4 that provides much more accurate planning when it comes to graft numbers/graft groupings/hair types/ areas of allocation etc. 

You just need to take a look at the results of guys on here who have had 1 HT vs. multiple HT’s to see the difference in quality that is able to be achieved. 

 

[Xanadu]

2 hours ago, Curious25 said:

One of the main advantages with a more conservative initial intervention, is for analysis of how the patient takes to surgery, and what his growth rate was. 
 

Aside from that, Surgeries with a smaller number of grafts leads for a higher likelihood of achieving a high graft survival rate, less chance of trauma and transection to the donor, and a better look at the landscape for surgery number 2/3/4 that provides much more accurate planning when it comes to graft numbers/graft groupings/hair types/ areas of allocation etc. 

You just need to take a look at the results of guys on here who have had 1 HT vs. multiple HT’s to see the difference in quality that is able to be achieved. 

 

Yes, that's understandable if the graft numbers differ. But I am seeing cases with very similar graft numbers. The only difference is where they are put. Both are also a two-step approach.

[HugoX]

Or type 3 like I did, over 7000 grafts first session and cover whole scalp equally (did another over 3500 grafts 10 months later) 

[Curious25]

16 minutes ago, HugoX said:

Or type 3 like I did, over 7000 grafts first session and cover whole scalp equally (did another over 3500 grafts 10 months later) 

You’ve had incredible results , and have gone to a seemingly top of his game Dr - but the fact still Remains, a mega session, or any session over 3000 grafts for that matter, is still classed as a higher risk approach to take, purely for the fact of the matter that if you are indeed patient X, and the grafts don’t take - you have lost a huge chunk of a finite resource. 

 

31 minutes ago, Xanadu said:

Yes, that's understandable if the graft numbers differ. But I am seeing cases with very similar graft numbers. The only difference is where they are put. Both are also a two-step approach.

The theory is the same , regardless of whether graft numbers are the same or different between the sessions - the emphasis is placed on being conservative with the graft number in the initial surgery. 

[Xanadu]

3 hours ago, Curious25 said:

You’ve had incredible results , and have gone to a seemingly top of his game Dr - but the fact still Remains, a mega session, or any session over 3000 grafts for that matter, is still classed as a higher risk approach to take, purely for the fact of the matter that if you are indeed patient X, and the grafts don’t take - you have lost a huge chunk of a finite resource. 

 

The theory is the same , regardless of whether graft numbers are the same or different between the sessions - the emphasis is placed on being conservative with the graft number in the initial surgery. 

Yes, but the mount is the same in the two approaches, so the amount you will have lost if they don't take is the same. So I don't see any of these being more conservative than the other - do you?

Maybe you could even claim that method 2 is more safe, because at least you will have tested the crown a bit and will have an idea whether it 'takes' or not?

[Gatsby]

The best approach is dictated by the patient's head size, donor density, 5ari medis, beard density (if applicable) and other factors. No two patients are the same in any one Norwood scale. The Norwood scale is really just a guide or a template. Look at the many variations of patients who are classified as Norwood 6. All the best.

[Curious25]

7 hours ago, Xanadu said:

Yes, but the mount is the same in the two approaches, so the amount you will have lost if they don't take is the same. So I don't see any of these being more conservative than the other - do you?

Maybe you could even claim that method 2 is more safe, because at least you will have tested the crown a bit and will have an idea whether it 'takes' or not?

I understand what you mean now, after updating your original post. 
 

So using 3000 as a generic number on a slick NW6, you are wondering about the difference between focusing all these 3000 grafts on the front vs. focusing 2300 grafts at the front, and maybe 700 across mid scalp and crown? 
 

I imagine this entirely boils down to patient and Dr goals. Maybe, if a small head size, the dr would be concerned about transplanting all 3000 in just the front section, and wished to spread out the recipient area to help lessen the risk of overwhelming the blood supply demands - however in general, from a yield perspective, it shouldn’t really make a difference. 

[HugoX]

11 hours ago, Curious25 said:

You’ve had incredible results , and have gone to a seemingly top of his game Dr - but the fact still Remains, a mega session, or any session over 3000 grafts for that matter, is still classed as a higher risk approach to take, purely for the fact of the matter that if you are indeed patient X, and the grafts don’t take - you have lost a huge chunk of a finite resource. 

This is a interesting statement, also one that a read here and there, it's a fact you say but what fact and statistics are you referring to? I like empirical data (work damaged) can you show me data that shows 100 patients going to a reputable well known serious doctor who knows what they are doing, out of those 100 patients how many did no grafts take at all?  Because saying its a risk, sure everything in life is a risk but if the risk is 1 patient out 10 000, 1 out  of 100k....then this is minuscule and not a big risk. But if as you say its a FACT then there need to be 1 out 10, or 1 out 100....then sure, bit risk 

[Curious25]

4 hours ago, HugoX said:

This is a interesting statement, also one that a read here and there, it's a fact you say but what fact and statistics are you referring to? I like empirical data (work damaged) can you show me data that shows 100 patients going to a reputable well known serious doctor who knows what they are doing, out of those 100 patients how many did no grafts take at all?  Because saying its a risk, sure everything in life is a risk but if the risk is 1 patient out 10 000, 1 out  of 100k....then this is minuscule and not a big risk. But if as you say its a FACT then there need to be 1 out 10, or 1 out 100....then sure, bit risk 

It’s not a data driven fact rather it a logical perspective.

I’m sure there are stats out there as to how many patient x’s exist, that I unfortunately don’t have to hand - nor is it something that I imagine would be too transparent of a figure to accurately assess, given it not being in any clinics interests to promote;  however it is no industry secret that pretty much every major clinic provides patients with education and disclaimers in regards to the potential for a surgery not to yield as is intended for X, Y and Z reasons, prior to going under the knife. Combined with the number of patient cases you can find online, where yield hasn’t been of desired expectation. 

At the end of the day, it is down to the individuals risk vs. reward appetite, as are most decisions we make in life. There is no definitive right or wrong choice, as such. If you as an informed and educated patient are happy with your choice of Dr, and the agreed upon strategy, then all power to you. 

I don’t feel like it’s too alarming of a statement to make, that utilising a very large proportion of a finite resource in one go, is a riskier decision to make than utilising a lesser number of said source, given the unknowns that may occur, , , so I’m not sure where else the conversation can go from here?  

[HugoX]

7 hours ago, Curious25 said:

It’s not a data driven fact rather it a logical perspective.

I’m sure there are stats out there as to how many patient x’s exist, that I unfortunately don’t have to hand - nor is it something that I imagine would be too transparent of a figure to accurately assess, given it not being in any clinics interests to promote;  however it is no industry secret that pretty much every major clinic provides patients with education and disclaimers in regards to the potential for a surgery not to yield as is intended for X, Y and Z reasons, prior to going under the knife. Combined with the number of patient cases you can find online, where yield hasn’t been of desired expectation. 

At the end of the day, it is down to the individuals risk vs. reward appetite, as are most decisions we make in life. There is no definitive right or wrong choice, as such. If you as an informed and educated patient are happy with your choice of Dr, and the agreed upon strategy, then all power to you. 

I don’t feel like it’s too alarming of a statement to make, that utilising a very large proportion of a finite resource in one go, is a riskier decision to make than utilising a lesser number of said source, given the unknowns that may occur, , , so I’m not sure where else the conversation can go from here?  

Conversation doesn't need to go anywhere, I was just curious as I hear this statement used by people here and there without actual facts and statistic to back it up and I thought you might have this info as you wrote it's a fact...😅. 

Even here at the forum it's possible to do a somewhat research and see of the people that have performed surgery (making it easier we include all clinics, even the ones where a 20 year old "technician" doing everything) how many had 0 to 10% yield, 10-20% and so on, no questions about Doctors or clinic, just yield.. Maybe Melvin can do a poll 🤔. 

For me data and statistics comes before logic, otherwise I wouldn't have taken over 10 years to research and learn and how to minimise risks. 

[Xanadu]

On 11/2/2022 at 6:44 AM, Curious25 said:

I understand what you mean now, after updating your original post. 
 

So using 3000 as a generic number on a slick NW6, you are wondering about the difference between focusing all these 3000 grafts on the front vs. focusing 2300 grafts at the front, and maybe 700 across mid scalp and crown? 
 

I imagine this entirely boils down to patient and Dr goals. Maybe, if a small head size, the dr would be concerned about transplanting all 3000 in just the front section, and wished to spread out the recipient area to help lessen the risk of overwhelming the blood supply demands - however in general, from a yield perspective, it shouldn’t really make a difference. 

Yeah, it shouldn't right?

The one way where it might make a difference would be for the second procedure.

In the case of completely bald crown I am guessing it would be easier to place grafts without transsection on the ones already there. In other words they don't have to bob and weave between already exsiting hairs. On the other hand they don't know how many will take, and therefore cannot assess the final density as well.

In the case of having done both crown and midscalp with lower density first, the second procedure might be a bit more tricky (I'm not sure?) due to having to place in between the existing ones, but one has a clearer view of where the weaker spots are and can place there.

Does that sound about right?

[Curious25]

Second passes to increase density between existing hairs , for a high level m surgeon, should be a fairly standard and straight forward procedure to perform. An important factor is that the existing hairs are stabilised, however. 
 

I have personally seen more aesthetically pleasing and successful transplants, where two/three/four step strategies have taken place, and further density has been added into previous transplanted areas.