Criteria for dense packing

[Julius]

Dr Paul Shapiro has said in a previous post that dense packing should generally only be performed on people who are at least 30 and are unlikely to go beyond a Norwood 5. I was wondering do all coalition doctors have this standard. And if there are any forum members who have had dense packing and are less than thirty years of age? Cheers

[thanatopsis_awry]

Julius,

 

Others can chime in with more precise thought, but I think we need to first define what (we are considering) a densepack to be.

 

Also, since we are essentially dealing with donor management, how much donor one actually possesses is a monumentally important factor, along with the factors of age and likely pattern!

 

There have absolutely been cases posted on this forum of people sub-30 who had densepacks; whether these were appropriate, or whether Dr. Paul would consider them appropriate is a whole other story, and I think we'd have to evaluate them individually.

 

Again, I think we really need to define what we are saying a "densepack" is; I'm pretty certain Dr. Feller considered my case a "densepack", e.g.

 

Good topic.

[Julius]

Thanks thana, considering the result that makes sense, but at what density was your ht?

I would call anything over 45 grafts per cm2 dense packing and super dense packing anything over 60 grafts per cm2. Density also obviously depends on the numder of hairs in each graft.

[mattj]

I could be wrong but I think the majority of under-30 transplant patients who have gone to doctors who can 'dense pack' will have had this done, if you take your own definition of dense pack. In fact most will likely have had grafts transplanted to 60 or more per square centimeter. (I'm talking about at the leading edge of the hairline.)

[Julius]

Wow! What is Dr Rahal's definition of dense pack? As for most hair transplants on patients under 30 having grafts transplanted at 60 or more per cm2, even on the hair line, wouldn't that scream ht? I thought that most hairlines where done with singles at 45-55 grafts per cm2 max? Would that even be ethical to super dense pack patients at that age considering their likely future loss? Cheers

[the B spot]

In SMG's case, Dr. Ron developed his hairline techniques to mimic naturalness and provide density with the appropriate number of grafts per sq cm.

 

In most cases 40-55 fu cm/2 provides our patients with excellent results. We get maximum yield at this number, but Dr. Ron and Dr. Paul will occasionally go above this given the proper prerequisites as mentioned above..we still get max growth, but we only do this on a select patients.

 

The leading edge/transition zone is all singles of varying density (about 1cm wide) then the 1's and 2's closely placed together in the defined zone (2 cm wide_ followed by 2's,3's and 4's into the frontal core to prevent a see through look/block light.

 

Matt Zupan (SMG's Patient Educator) likes to use the forest analogy...the forest is always less dense on the edge, progressively getting more dense as you go in. The same can be said for mother natures hairlines.

 

A "Dense Pack" is only for patients who, after weighing ALL factors and in the estimation of the doctor, can afford to use a higher number of grafts that would normally be saved for future loss. Most patients are NOT candidates for this, contrary to what has circled the internet the past few years.

 

Each doctor will have their own techniques, including the amount of grafts, angulation, graft distribution, approach, etc... which a patient should take into consideration before pulling the trigger.

 

Additionally, one needs to consider the reputation, length of practice, transparency, consistency of results, patient care, staff and judge accordingly.

 

Take Care,

Jason

 

Edited for clarification.

[thanatopsis_awry]

Julius, I'm honestly not even sure what my hairline density distribution is -- but it's something I'm actually pretty curious to know.

 

B, using 2-3 hair grafts behind the leading edge --> do you feel you guys do this, at least do it closer to "the edge", moreso than other docs who might be in question? I've thought most top docs would do this, but I suppose the philosophy and tecnique in just how close to the edge one goes could be varied (?)

 

Also, re: what Matt mentioned above....I'm pretty certain that with Dr. Feller the leading edge of my hairline *isn't* at the highest density, but that the zone behind the "leading edge" is where I had the highest density implanted.

 

Anyways, I'd agree that a "densepack" is really weighted against the individual charachteristics of an individual. I feel like I have good density, but that the number of grafts currently allocated *isn't* in line with a "densepack", in the sense that a disproportionate number wasn't invested in my hairline.

 

Were I to ever add grafts to my hairline zone I would definitely consider *that* a densepack, since the grafts being allocated would be a bit hair-greedy and basically pumping up an already solid region at the potential expense of a different region down the road.

[Forrest Gump]

I am about 35, and I had dense packing. I have about 60 per cm2 in my frontal hairline, and my doctor and I both agreed upon it.

[Julius]

Thanks for your replies, B spot are you saying that in most cases 40-55 grafts cms per cm2 are used in the hairline then a greater density past the transition zone? I had a previous discussion with Raj about the best density on the hairline and the rest of the head so that it doesn't show up under harsh lighting and we seemed to come to the consensus that a high mature hairline with about 45-55 grafts per cm2 at the hairline (using singles) and 55-65 on the rest of head would hold up and look naturally age appropriate. Forest, who did your procedure and at what stage on the Norwood scale were you? Cheers

[RajToor]

I do agree that higher density on the hairline and less density on the head wont look natural under harsh lighting and people would easily know its a HT job.

[the B spot]

J

[the B spot]

Originally posted by the B spot:

Right Thana... the outlying singles will be thinner, then the transition zone will be progressively thicker, getting to the greater density of the defined zone/frontal core.

 

Julius, even if you transplanted 45-50 singles, 35 2 hair grafts would have greater density as would 30 2+3 hair grafts, so it is not necessarily the graft totals that you use to determine how a HT will look.

 

Hope this is what your looking for =)

 

Take Care,

Jason

[Dr. Paul Shapiro]

The following quote by my brother Dr. Ron Shapiro eloquently summarizes what we are doing when we perform a hair transplant surgery:

 

 

'In hair restoration surgery we are trying to redistribute a limited amount of donor hair, with minimal waste and maximum survival, to a potentially expanding bald or thinning recipient area. We want to accomplish this redistribution in a manner that insures the patient will be satisfied with the results now and in the future. Patient satisfaction is dependent on meeting his/her expectations of naturalness, density, and amount of work needed.'

 

The guidelines I mentioned in my post on dense packing take these basic principles in mind. ( http://hair-restoration-info.c...21087683&m=929107493)

At what densities we get minimal waste with maximum survival is a judgment call that we need to make on an individual basis with each patient. The guidelines I set in my post are just guidelines. I think they represent common sense. I chose the age of 30 because I think it is very difficult to predict future hair loss when a patient is in their 20's. I feel more comfortable predicting future hair loss in patients in their 30's but even then it can be difficult. There are times that going outside of these guidelines may be appropriate as long as the risk and benefits are discussed in detail with the patient. Sometimes to get the high graft count needed in large cases we go outside the textbook 'safe' donor area. And sometimes in order to dense pack we use up donor in the front half knowing that there may not be enough donor to plant at similar densities in the temporal humps or top of the crown if the patient progresses to a Norwood type 6 or 7. I have had patients who say they are comfortable with this risk because they would rather look their best while they are young. It is judgment call to decide whether the benefits outweigh the risk. At the same time I do feel that younger patients sometimes do not completely understand the risk they are taking in using up a lot of donor and/or dense packing, especially if they are in there 20's. When I was in my 20's, fifty years old sounded like an old man to me. But I am going to be 55 my next birthday and that does not feel old to me at all. And a lot of my peers are single and in the dating scene and want to look the best they can. Unfortunately the divorce rate in the US is greater than 50% so a lot of guys will be single again even if they are married.

 

As I showed in my post on dense packing that at SMG we can dense pack at densities up to 75FU/sqcm using the proper magnification and small custom cut blade. But this type of cases should only be done in the appropriate patients and I find that the majority of patients do not qualify for this type of sessions.

 

Below is a quick review of the math involved in hair transplantation. When we are transplanting in the front ?? to the front 2/3 of the scalp we are covering an area that can measure from 80sq.cm. up to 150 sq.cm. If we were to plant at a density of 40Fu/sqcm we would need 3,200 to 6,000 FU grafts. If we were to plant at densities of 60 FU/sq.cm we would need 4,800 to 9,000 FU grafts. You can see that if we plant at the higher density of 60 FU/sqcm that does not leave much donor left for future hair loss. (This is the surface area needed to cover if one becomes a Norwood type 6 and the area can vary depending on how high ones temporal humps are)

 

We need to carefully pick which patients we chose to dense pack. Even thought the procedure could look great today, we could paint ourselves into a corner so that 10 to 20 years down the road patient has an unnatural look and there is not enough donor left to make the transplant look natural. Unfortunately it takes that long to sometimes see the downside of what we do in a hair transplant.

 

Dr. Paul Shapiro

[Julius]

Thank you for taking the time to elucidate that for me Doctor. I can definitely understanding those who are slowly receding taking the "risk because they would rather look their best while they are young". Forest, at that density does your ht hold up under harsh light? Cheers