Anyone noticing the weird new design of H&W graft placement?

[stephcurry30]

Why is H&W placing these grafts in rows and columns? This reminds me of D****'s work where he was called out not to long ago! As someone who has been researching HT for a while now, this is something that is considered unnatural and not good. Why is H&W doing this?

All photos attached are from the threads below.

 

 

 

 

[A_4_Archan]

Yeh they are been doing this and i have seen all those shared cases plus many more other cases on various forums where they implanted in rows 

[gaz9318054]

This is nothing new.

1 hour ago, stephcurry30 said:

Why is H&W doing this?

The explanation is in the original post of the first topic you linked to.

Whether or not the strategy is effective is another matter, but the results should speak for themselves.

[stephcurry30]

1 hour ago, gaz9318054 said:

This is nothing new.

The explanation is in the original post of the first topic you linked to.

Whether or not the strategy is effective is another matter, but the results should speak for themselves.

That explanation makes 0 sense to me!

[MaximusEastwood]

Fwiw I asked Dr. Wong about this and he said it’s to help pack the grafts more closely and that you can’t tell it’s in rows once it grows out 🤷‍♂️

[Chrisno]

2 main reasons:

1. If you place among existing native (thinning) hair it's best because you get a better uniform result among existing hairs. This is important for diffuse thinners
2. Mathematically, if you want to dense pack as much as possible, a row-like approach yields the highest density within a square centimeter. The rows are staggered. Keep in mind that a fresh implant (first few days) seems much more visually "harsh" than what it will look like once everything is healed due to the blood surrounding the grafts after placement.

Hairs actually does not grow in a random pattern. They grow in groups of patterns. See this document otulining the lateral slit technique where this is discussed: https://hassonandwong.com/wp-content/uploads/2015/06/lateral_slit.pdf

 

 

Edited August 21, 2023 by Chrisno

[Emiry]

Strange indeed. I thought this was considered amateurish and something cheap hairmills did. 

[Fue3361]

I'm not a fan at all of using rows.  Now, does rows necessarily mean a bad result?  No.  But is it ideal, hell no.  It's just lazy.  There's no argument you can make that you "couldn't do it more randomly".  Rows are just easier to do for a surgeon.  Any other explanation is an excuse to make the surgery easier to do.

[stephcurry30]

17 hours ago, MaximusEastwood said:

Fwiw I asked Dr. Wong about this and he said it’s to help pack the grafts more closely and that you can’t tell it’s in rows once it grows out 🤷‍♂️

3 hours ago, Chrisno said:

2 main reasons:

1. If you place among existing native (thinning) hair it's best because you get a better uniform result among existing hairs. This is important for diffuse thinners
2. Mathematically, if you want to dense pack as much as possible, a row-like approach yields the highest density within a square centimeter. The rows are staggered. Keep in mind that a fresh implant (first few days) seems much more visually "harsh" than what it will look like once everything is healed due to the blood surrounding the grafts after placement.

Hairs actually does not grow in a random pattern. They grow in groups of patterns. See this document otulining the lateral slit technique where this is discussed: https://hassonandwong.com/wp-content/uploads/2015/06/lateral_slit.pdf

 

 

This makes no sense to me. I don't see how implanting in rows gives you a better density? Regardless of the pattern a patient's head will still get x number of grafts placed in a same sq cm^2 area meaning the pattern is irrelevant. You'll walways have the same natural of grafts over a given area. And hair is not naturally growing out in rows and columns. If you buzz cut your hair, you will never see hair growing out in rows/columns. What is the patient wants to wear his hair short? This would be a incredibly wierd design. 

 

2 hours ago, Emiry said:

Strange indeed. I thought this was considered amateurish and something cheap hairmills did. 

 

8 minutes ago, Fue3361 said:

I'm not a fan at all of using rows.  Now, does rows necessarily mean a bad result?  No.  But is it ideal, hell no.  It's just lazy.  There's no argument you can make that you "couldn't do it more randomly".  Rows are just easier to do for a surgeon.  Any other explanation is an excuse to make the surgery easier to do.

 

I agree with this as well. I remember a D**** thread a while ago about a patient complaining as to why grafts were implanted in rows and columns and everyne agreeed it was unnatural and make the hair/hairline way too harsh. I've really only saw this pattern in 3 types of clinics: Hair mills, D****'s and H&W

 

[Chrisno]

@stephcurry30 did you look at the .pdf I linked to? See how natural hairs grow in groups of row-like patterns. I could see this exact pattern when I shaved the back of my head for my procedure with Dr. Hasson. Below picture is from their .pdf which I linked to.

I can't speak to how Dr. Wong implants. But Hasson implanted me at 85 FU per cm2, and I can assure you it does not look like rows the way you describe it.

As an exercise, you could try marking out 1 sq cm on a piece of paper, grab a pen, and try filling in as many 'dots' as you can. You can fill much more 'dots' using a pattern similar to the above pictures vs. a complete 'random walk' pattern. Keep in mind there must be a certain minimum distance between incisions to make sure there is enought support around each graft and the incisions does not collapse on each other. If you want a density almost matching your native density, this is the way you should implant in my opinion. But they need to be staggared, of course, as is seen in the picture above.

Note 1: all the cases you linked to are from Dr. Wong, and all those patients where implanted among existing hair, i.e., not a completely bald scalp.
Note 2: JT talked about this implementation method/pattern in an extensive Reddit post some months back

Edited August 21, 2023 by Chrisno

[BurnieBurns]

My understanding is these reasons.

- Minimises skin trauma, protects native hair without compromising density

- Optimising graft survival and mitigates shock loss

- Provides good spacing for adding more density in future if required

After my surgery with Dr Wong, there was a row appearance on the implants. After a couple of months, it's never looked row-like since and the density is fantastic.

[BDK081522]

Here's a simple litmus test. Do you see any of the other elite surgeons who achieve the most natural, dense, jaw dropping results implanting in rows? Ever see this from Zarev, Couto, or Konior? If no, then this is not the way. 

[Melvin- Admin]

I think there needs to be differentiation between vertical rows and horizontal rows. 

As you can see, some close dense-packed fu’s do appear “row” like horizontally in nature. People talk about this issue with De Freitas and he has some of the best work I’ve ever seen. 

 

Take a look at this case for example. There are fu’s dense-packed next to one another horizontally, similar to H&W. Now, look at it grown out. The naturalness, the appearance. It’s a work of art. 

 

Bottomline, don’t judge results based on post-op pictures. Judge them when they grow out. 

[WoundedWolf]

I think its clearly a bad and poor design because even if the angles, the depth and direction , density of grafts are all proper with the rows (vertical or horizontal patterns both) are identified easily by human eyes. 

one thing surgeons should always do is mimic nature which has randomness instead for easy work they plant in rows which is lazy 

if you observe nature there is a difference between farmland and wild forest, farmland shows plantation done in rows by humans whereas forests look more natural

so I would stay as far as possible from surgeons who plant in rows, as I myself have experienced this with my 1st transplant

[WoundedWolf]

5 hours ago, BDK081522 said:

Here's a simple litmus test. Do you see any of the other elite surgeons who achieve the most natural, dense, jaw dropping results implanting in rows? Ever see this from Zarev, Couto, or Konior? If no, then this is not the way. 

Yes they dont impant in rows from the post-op pictures which i have seen 

[WoundedWolf]

2 hours ago, Melvin- Moderator said:

I think there needs to be differentiation between vertical rows and horizontal rows. 

As you can see, some close dense-packed fu’s do appear “row” like horizontally in nature. People talk about this issue with De Freitas and he has some of the best work I’ve ever seen. 

 

Take a look at this case for example. There are fu’s dense-packed next to one another horizontally, similar to H&W. Now, look at it grown out. The naturalness, the appearance. It’s a work of art. 

 

Bottomline, don’t judge results based on post-op pictures. Judge them when they grow out. 

Hey melvin, i can see some randomness in first 0.3mm but after that the hairs even though are densed packed it seems its planted in horizontal lines, now some people dont obeserve this but some people who look carefully they  identify ask questions like if its a different hair cut or did you did something on hair (i received these comments as well)

[Emiry]

27 minutes ago, WoundedWolf said:

one thing surgeons should always do is mimic nature which has randomness instead for easy work they plant in rows which is lazy 

One thing I was impressed from and I believe is the reason why nobody not even people who know I had a hair transplant can tell I had a transplant is because my surgeon Pekiner took time planning and implanting every graft. That’s some insane level of dedication and attention to detail. He would do one incision then think and plan the next one, he spent hours implanting and took care of every implanted graft. It’s why everyone thinks I have natural hair now.

Nature is imperfect and it’s what makes nature so beautiful and hard to recreate. There is no perfection. In the randomness is the perfection. Your analogy of farmland and forests is perfect. 

[WoundedWolf]

5 hours ago, Emiry said:

One thing I was impressed from and I believe is the reason why nobody not even people who know I had a hair transplant can tell I had a transplant is because my surgeon Pekiner took time planning and implanting every graft. That’s some insane level of dedication and attention to detail. He would do one incision then think and plan the next one, he spent hours implanting and took care of every implanted graft. It’s why everyone thinks I have natural hair now.

Nature is imperfect and it’s what makes nature so beautiful and hard to recreate. There is no perfection. In the randomness is the perfection. Your analogy of farmland and forests is perfect. 

Same example can be taken for hairline and sea shore, when looked from a distance it should have a specific shape and when we look closer random irregularities appears and magic happens

[Bandit90]

When I see implantation in rows/columns to me this comes across as the surgeon is taking a scientific approach over an artistic approach. I think these results will come out good, but will just maybe lack that artistic flare. H&W arent the only top clinic doing this approach, I have seen cases by Dr Bisanga using a similar graft arrangement. TBH I dont think it will make a huge difference so long as the angles are good. Implanting in rows also requires more grafts, so in higher norwood cases where you need to get good mileage then an artistic approach will almost be more beneficial. I take Dr Konior work as a good example due to his artistic flair he gets so much more coverage from less grafts. 

[BaldReaper]

On 8/21/2023 at 1:53 PM, Chrisno said:

@stephcurry30 did you look at the .pdf I linked to? See how natural hairs grow in groups of row-like patterns. I could see this exact pattern when I shaved the back of my head for my procedure with Dr. Hasson. Below picture is from their .pdf which I linked to.

I can't speak to how Dr. Wong implants. But Hasson implanted me at 85 FU per cm2, and I can assure you it does not look like rows the way you describe it.

As an exercise, you could try marking out 1 sq cm on a piece of paper, grab a pen, and try filling in as many 'dots' as you can. You can fill much more 'dots' using a pattern similar to the above pictures vs. a complete 'random walk' pattern. Keep in mind there must be a certain minimum distance between incisions to make sure there is enought support around each graft and the incisions does not collapse on each other. If you want a density almost matching your native density, this is the way you should implant in my opinion. But they need to be staggared, of course, as is seen in the picture above.

Note 1: all the cases you linked to are from Dr. Wong, and all those patients where implanted among existing hair, i.e., not a completely bald scalp.
Note 2: JT talked about this implementation method/pattern in an extensive Reddit post some months back

You cant seriously believe he implanted you with 85g/cm2

[Fue3361]

2 hours ago, BaldV said:

You cant seriously believe he implanted you with 85g/cm2

Mine was over 80 in some areas, with complete randomness and no rows.  

[Dr. Jerry Wong]

One of the most enjoyable aspect of this job is the opportunity to try out new ideas. Lots of ideas simply did not work but the ones that do have let to advancements like custom cut blades, depth control for recipient sites, mega and giga sessions, and lateral/coronal slits for angle control all of which had been major advancements in our field. I have learned that over the years scalp have different tolerances to trauma which is why the same parameters that grow well in one person may do poorly in another. Sometimes we know about risk factors such as smoking and diabetes and take precautions in advance but often there are no advance warnings nor signs that hair may grow poorly in any one individual. The search for consistent hair growth is ongoing no matter how experienced or how good we are as hair surgeons. I don't and will never bat 100% but my bating average has improved and are still improving. 

I would like to discus some of the changes I made in the last 8 years that have made my work better. Cutting thousands of sites on the scalp in one session is extremely stressful for the skin and any changes that can reduce skin or vascular damage even by a small percentage is significant. By switching from single 0.2 mm thick) to double edge  (0.1 mm) razor blades there were less bruising and slight improvement in hair growth as the thinner blades cuts cleaner with less trauma. 7 years ago I modified an implanter that enable me to place grafts into much smaller slits. Smaller blades =less trauma to the skin and implanters eliminates possible forceps trauma to the bulb. This made a major improvement in growth consistency esp. when grafts are dense packed. The last few years have been spend fine tuning slit size, depth and density.

I have always cut slits in rows. I have compared random and row slits and have found rows ( in my hands) provide better coverage and density. Making rows with single blade seldom looks like rows as the rows are never straight and there are slight variations between side to side and front to back cuts which means some spots on the skin will be more damaged than others which might explain why some transplants have areas of uneven growth. If the spacing can be controlled and more evenly spaced would the growth be more consistent. I have been looking for a 3 blade handle for years to hold the thinner blades that I'm currently using. 2 years ago I managed to develop one that works. Unlike multi handles that came before where blade size and spacing is fixed my handle adjust for any sized bade and spacing allowing surgeon to choose the perfect sized blade for the graft size. I cut the rows as straight as possible to keep the front to back spacing as even as possible produce and the handle provide perfectly even spacing side to side. I almost never see bruising of the skin as I now have very accurate control of spacing which was not possible with single blade. Even spacing prevents localized stressed spots on the skin (area cut too close with single blade).  From 2 years of observation I have found growth is more consistent with 3 blade handle as compared to single blade handle. The concern that hair will look artificial has not not materialized provides that the density is kept above 35 to 40/cm2. Row effect is seen during early healing phase. 10 to 12 days post op once the crusts are washed off the rows are no longer  seen. Cutting slits below 30/cm2 best to use single handle and cut at random. 

I'm the only person at Hasson and Wong that uses the multi handle Dr. Hasson does not use it and has nothing to do with this devise. I know that there will be pushback and a lot of people can only see the negative side of this devise. Any negative feedback should be directed at me and not Hasson and Wong. This handles biggest advantage is that it does reduce skin damage and provide more consistent growth.  In 1996 when I introduced the lateral slit technique with the feedback being mostly either negative or why would you want o do that? But I knew that by controlling the hair angle the cosmetic result is far superior than any current technique. A lot of my patients are concerned when they see the row post op but once the crusts are gone it looks fine. How natural a transplant looks has more to do with angle control than anything else, if a surgeon does not understand angles and how to control it what you end up is a mess no matter what else you do. I do not imposed my techniques on anyone and if patient tells me he does not want row effect even foe a few days I will cut with single blade handle. There are pros and cons to any technique I know that with this instrument the pros far out weight the cons. 

 

[Melvin- Admin]

5 minutes ago, Dr. Jerry Wong said:

One of the most enjoyable aspect of this job is the opportunity to try out new ideas. Lots of ideas simply did not work but the ones that do have let to advancements like custom cut blades, depth control for recipient sites, mega and giga sessions, and lateral/coronal slits for angle control all of which had been major advancements in our field. I have learned that over the years scalp have different tolerances to trauma which is why the same parameters that grow well in one person may do poorly in another. Sometimes we know about risk factors such as smoking and diabetes and take precautions in advance but often there are no advance warnings nor signs that hair may grow poorly in any one individual. The search for consistent hair growth is ongoing no matter how experienced or how good we are as hair surgeons. I don't and will never bat 100% but my bating average has improved and are still improving. 

I would like to discus some of the changes I made in the last 8 years that have made my work better. Cutting thousands of sites on the scalp in one session is extremely stressful for the skin and any changes that can reduce skin or vascular damage even by a small percentage is significant. By switching from single 0.2 mm thick) to double edge  (0.1 mm) razor blades there were less bruising and slight improvement in hair growth as the thinner blades cuts cleaner with less trauma. 7 years ago I modified an implanter that enable me to place grafts into much smaller slits. Smaller blades =less trauma to the skin and implanters eliminates possible forceps trauma to the bulb. This made a major improvement in growth consistency esp. when grafts are dense packed. The last few years have been spend fine tuning slit size, depth and density.

I have always cut slits in rows. I have compared random and row slits and have found rows ( in my hands) provide better coverage and density. Making rows with single blade seldom looks like rows as the rows are never straight and there are slight variations between side to side and front to back cuts which means some spots on the skin will be more damaged than others which might explain why some transplants have areas of uneven growth. If the spacing can be controlled and more evenly spaced would the growth be more consistent. I have been looking for a 3 blade handle for years to hold the thinner blades that I'm currently using. 2 years ago I managed to develop one that works. Unlike multi handles that came before where blade size and spacing is fixed my handle adjust for any sized bade and spacing allowing surgeon to choose the perfect sized blade for the graft size. I cut the rows as straight as possible to keep the front to back spacing as even as possible produce and the handle provide perfectly even spacing side to side. I almost never see bruising of the skin as I now have very accurate control of spacing which was not possible with single blade. Even spacing prevents localized stressed spots on the skin (area cut too close with single blade).  From 2 years of observation I have found growth is more consistent with 3 blade handle as compared to single blade handle. The concern that hair will look artificial has not not materialized provides that the density is kept above 35 to 40/cm2. Row effect is seen during early healing phase. 10 to 12 days post op once the crusts are washed off the rows are no longer  seen. Cutting slits below 30/cm2 best to use single handle and cut at random. 

I'm the only person at Hasson and Wong that uses the multi handle Dr. Hasson does not use it and has nothing to do with this devise. I know that there will be pushback and a lot of people can only see the negative side of this devise. Any negative feedback should be directed at me and not Hasson and Wong. This handles biggest advantage is that it does reduce skin damage and provide more consistent growth.  In 1996 when I introduced the lateral slit technique with the feedback being mostly either negative or why would you want o do that? But I knew that by controlling the hair angle the cosmetic result is far superior than any current technique. A lot of my patients are concerned when they see the row post op but once the crusts are gone it looks fine. How natural a transplant looks has more to do with angle control than anything else, if a surgeon does not understand angles and how to control it what you end up is a mess no matter what else you do. I do not imposed my techniques on anyone and if patient tells me he does not want row effect even foe a few days I will cut with single blade handle. There are pros and cons to any technique I know that with this instrument the pros far out weight the cons. 

 

Thanks for this insightful response Dr. Wong. I agree that at higher density it isn’t visible. There’s another top doctor in Spain following a similar pattern, and the growth is always very high. The good news for patients is that this customized and tailored for the patient. If a patient doesn’t want this method, they can opt for the single blade, which is great to know in the community. I’m interested to hear what other surgeons think of this approach.

I wonder if surgeons that struggle with growth and yield could adopt this method. For the crown this approach makes a lot of sense, since high density and high growth is critical to achieve visible density.

[BaldReaper]

9 hours ago, Fue3361 said:

Mine was over 80 in some areas, with complete randomness and no rows.  

You are a rear exception

[Chrisno]

13 hours ago, BaldV said:

You cant seriously believe he implanted you with 85g/cm2

Here you go, count them. Red area is exactly 1 sq cm of my scalp, that was completely bald before my transplant, i.e., no native hairs there. 85 grafts. My entire transplant is this dense.

Photo is from 8 days post op when all scabs were off. As you can see, no visible 'rows'.