Question/Answer: Are Higher Densities Always Superior?

[Bill - Seemiller]

This information can also be found in our Hair Loss Q&A Blog by clicking here.

 

Blog Title:

 

Are Higher Densities Always Superior?

 

Question:

 

What is the highest density in follicular units per square cm that can be achieved with a hair transplant?

 

Answer:

 

This is a question that is commonly asked. Though it is certainly a valid question, one has to be careful what they do with the answer. Often, there are false assumptions that are made when it comes to density. Before I answer the question, therefore, allow me to point out some of these false assumptions.

 

False Assumption 1: If a hair transplant doctor can achieve 80 follicular unit grafts per square cm, that must mean, I can expect to achieve this.

 

False Assumption 2: All patients, no matter what their level of hair loss can expect to achieve the highest possible level of density.

 

False Assumption 3: Patients who receive lower levels of density must have received a sub-par hair transplant - therefore that hair transplant physician must not be as adequate as those who deliver higher density hair transplants.

 

False Assumption 4: Doctors who report that they can achieve higher levels of density must be better hair transplant doctors.

 

All of the above are false.

 

Listed below are a few things one must understand about hair transplantation and hair density.

 

1. Density is typically measured in follicular unit grafts per square cm. Since follicular units contain 1s, 2s, 3s, and 4 haired grafts, the appearance of density will vary depending on how many hairs are contained in each follicular unit graft. That means it is possible that 40 FU grafts/square cm containing mostly 2 hair grafts will appear more dense than 60 FU grafts/square cm containing mostly 1 hair grafts.

 

2. For patients with higher levels of hair loss, one cannot achieve both high densities and full coverage. One will have to be sacrificed to achieve the other since the donor supply is finite. Therefore a patient measured higher on the norwood scale may choose coverage over density.

 

In my opinion, the ideal hair transplant patient to receive super high density hair transplants are those patients who are older with low levels of hair loss. Transplanting hair densely packed in an area on a younger patient is risky since hair loss is unpredictable, and dense packed transplanted hair on an older person with extreme loss might leave a patient with unnatural balding pattern.

All quality hair transplant physicians who offer ultra refined follicular unit grafting, can achieve high level of densities when appropriate for the patient, up to approximately 80 follicular unit grafts per square cm.

 

However, I believe that patients shouldn't get too hung up on the numbers. Whereas higher numbers sound ultra-impressive - it doesn't signify a superior hair transplant. Instead, work with a quality hair transplant physician to determine the best course of action for you.

 

Bill

[Bill - Seemiller]

This information can also be found in our Hair Loss Q&A Blog by clicking here.

 

Blog Title:

 

Are Higher Densities Always Superior?

 

Question:

 

What is the highest density in follicular units per square cm that can be achieved with a hair transplant?

 

Answer:

 

This is a question that is commonly asked. Though it is certainly a valid question, one has to be careful what they do with the answer. Often, there are false assumptions that are made when it comes to density. Before I answer the question, therefore, allow me to point out some of these false assumptions.

 

False Assumption 1: If a hair transplant doctor can achieve 80 follicular unit grafts per square cm, that must mean, I can expect to achieve this.

 

False Assumption 2: All patients, no matter what their level of hair loss can expect to achieve the highest possible level of density.

 

False Assumption 3: Patients who receive lower levels of density must have received a sub-par hair transplant - therefore that hair transplant physician must not be as adequate as those who deliver higher density hair transplants.

 

False Assumption 4: Doctors who report that they can achieve higher levels of density must be better hair transplant doctors.

 

All of the above are false.

 

Listed below are a few things one must understand about hair transplantation and hair density.

 

1. Density is typically measured in follicular unit grafts per square cm. Since follicular units contain 1s, 2s, 3s, and 4 haired grafts, the appearance of density will vary depending on how many hairs are contained in each follicular unit graft. That means it is possible that 40 FU grafts/square cm containing mostly 2 hair grafts will appear more dense than 60 FU grafts/square cm containing mostly 1 hair grafts.

 

2. For patients with higher levels of hair loss, one cannot achieve both high densities and full coverage. One will have to be sacrificed to achieve the other since the donor supply is finite. Therefore a patient measured higher on the norwood scale may choose coverage over density.

 

In my opinion, the ideal hair transplant patient to receive super high density hair transplants are those patients who are older with low levels of hair loss. Transplanting hair densely packed in an area on a younger patient is risky since hair loss is unpredictable, and dense packed transplanted hair on an older person with extreme loss might leave a patient with unnatural balding pattern.

All quality hair transplant physicians who offer ultra refined follicular unit grafting, can achieve high level of densities when appropriate for the patient, up to approximately 80 follicular unit grafts per square cm.

 

However, I believe that patients shouldn't get too hung up on the numbers. Whereas higher numbers sound ultra-impressive - it doesn't signify a superior hair transplant. Instead, work with a quality hair transplant physician to determine the best course of action for you.

 

Bill

[TheHairLossCure]

Excellent post. I think the preoccupation with numbers of grafts per session and numbers of grafts per cm2 comes from the fact that lesser doctors will sometimes do surgeries that commit patients to more work, for lack of density or coverage. It would follow that bigger is better, and denser is better. This is true to an extent, but one must consider that HTs deal with a finite donor source. Some patients will have the pattern, age, hair characteristics, and skin characteristics for ultra-dense packing. Others will need to take a more conservative approach for the best long term aesthetic results. It should also be noted that the number of grafts transplanted in a session does not tell the whole story of how much hair mass is being transferred. One transplant may average 1.8 hairs per graft, while another will average 2.3 hairs or more. Since patients have a wide spectrum of needs different approaches are necessary. Luckily, with a good surgeon and cutting edge technologies, which may aptly be referred to as "ultra-refined," patients can expect good coverage and a natural result.

[nobuzz4me]

However, I believe that patients shouldn't get too hung up on the numbers. Whereas higher numbers sound ultra-impressive - it doesn't signify a superior hair transplant. Instead, work with a quality hair transplant physician to determine the best course of action for you.

 

Bill

 

 

 

Bill, great post and I agree completely with this statement. Each HT patient should be treated on a case by case basis and a great surgeon will be able to plan accordingly for each individual case. Lots of factors to consider, donor, age, expectations, density of donor, hair quality and texture, etc.

[TheEmperor]

There are a few guys at work who have HTs that I know of (maybe some that I dont know about).

 

The reason I can tell they are HTs is because they've got the tell-tale thick wall in the front with density that tapers off as it goes back -- usually a bald or sparse crown.

 

I'm starting to think that overall even coverage will look the most natural.

 

Hairs in the crown/midscalp are angled to grow forward, so spreading them out a bit more might not be such a bad idea. Its the same ammount of hair, the question is, do you want a thick non-see-thru hairline and a bald crown, or a see-thru hairline with coverage overall.

 

5 Years ago I would have said thick hairline, bald crown, but the girls didnt really mind the thin hair so much, however a bald crown is just that -- BALD.

[NervousNelly]

It all boils down to a matter of preference. I personally believe that the hairline and frontal region is the most important as that is what I see and most everyone around me. It is about balance. In the hands of a top physician they will not give you that "wall of hair" look. It will naturally blend into the thinner areas.

 

NN

[TheEmperor]

Originally posted by NervousNelly:

It all boils down to a matter of preference. I personally believe that the hairline and frontal region is the most important as that is what I see and most everyone around me. It is about balance. In the hands of a top physician they will not give you that "wall of hair" look. It will naturally blend into the thinner areas.

 

NN

 

Theres a guy at work whose HT Ive been watching grow. The work is good, the hairline conservative, but because the bald area in back is wide and goes down pretty far, you can tell its a HT.

 

I'm not saying it looks bad, but in this case, the conventional wisdom to build up the front makes it more obvious. Had they spread it out over the top, you might just think that he's thinning, but I believe the thinning hair would have still "framed his face."

 

Given the strategy that he went with, I think it looks as good as it can. I hope he is planning for a second.

 

I believe had he planted more in the mid and crown with it growing forward, it would have looked more natural.

 

Theres only so much a nor6 can do. So this begs the question:

 

Given that a guy with a large bald crown and nothing in front is going to need 7K grafts over two procedures, is it better to just do the front and save the crown for a second procedure, or go sparse overall and plant in between on the second?

 

In this case I think he should have opted for the latter, maybe gone back another inch on top and sprinkled the crown as well. What he's got now would never have occured naturally.

 

In this case, the doc has shown the abilty to create more density than what would be optimal.

[MrJobi]

To be honest, I do not know my Graft per Sq CM and my results are looking damn good! 5000 grafts for a N5 or so ( with a great doc) adds up to a nice head of hair !!

[NervousNelly]

Emperor,

 

I do hear what you are saying. It is really a tough call and I think that it comes down to a personal preference. If what you are telling me about the guy at your office is true, my immediate response is that it is not the best work because people can tell it is a HT. A top surgeon should be able to provide a nice hairline and transition things into the bald area so that it appears natural. I guess it might also boil down to available donor supply. Who knows, possibly the guy at work said "doc give me a dense, natural hairline and I could care less about the bald crown." Maybe he went against the Dr's recommendation.

 

Let me give you a what if scenario. What if he did spread things over the entire area and had no more donor available? or couldn't afford future HT? Now he is left with a very thin look, albeit possibly natural. He might be wishing he had a better, denser hairline.

 

See what I am saying, it is a tough call. I have seen some men that I thought had a great head of hair and they looked very young and then when they bent over, I noticed that they were quite thin or balding in mid to crown area. In that scenario I have always thought to myself, "that lucky bastard has a good hairloss pattern-I wish I would lose my hair that way." Who knows, maybe they had a transplant?

 

I think more creedance should be given to the placement of the hairline. The common mistake is that people want it too low. By being slightly more conservative, a lot of grafts can be saved because less realestate needs to be covered. When I told Dr. Shapiro that I wanted to keep my hairline high (conservative) he was happy and stated "Good, that will make things easier and I know that you will be much happier with the outcome."

 

I love this topic because there are so many variables that come into play. I would think that for a true artist of hair transplantation they would enjoy the challenges of a new canvas everyday.

 

Hope this helps.

 

 

NN

[TheEmperor]

Without seeing the guy im talking about, its hard to see what i'm saying.

 

There are two other HT guys in my company that I am aware of. They too opted to build up the front and mid section with some in the crown (perhaps native hair), but because they have not receded down so far in the back and sides, it works for them.

 

The guy I am talking about goes down pretty far in the back and the bacj/sides, so when you look at his profile, the new hair in the front is only connected to the rest by perhaps about an inch.

 

Again, it doesnt look terrible, but ANYONE who has looked into HT knows what it is. I dont think the additional front density adds much if anything to his look -- maybe only when hes looking in the mirror. Hes still got a big(wide) bald crown.

 

The other guy I had always suspected had a HT and one time he buzzed too low, I saw the hat-head U-shaped impression. Very good work though. Lots of density in front and well connected to the back.

 

Originally posted by NervousNelly:

Emperor,

 

I do hear what you are saying. It is really a tough call and I think that it comes down to a personal preference. If what you are telling me about the guy at your office is true, my immediate response is that it is not the best work because people can tell it is a HT. A top surgeon should be able to provide a nice hairline and transition things into the bald area so that it appears natural. I guess it might also boil down to available donor supply. Who knows, possibly the guy at work said "doc give me a dense, natural hairline and I could care less about the bald crown." Maybe he went against the Dr's recommendation.

 

Let me give you a what if scenario. What if he did spread things over the entire area and had no more donor available? or couldn't afford future HT? Now he is left with a very thin look, albeit possibly natural. He might be wishing he had a better, denser hairline.

 

See what I am saying, it is a tough call. I have seen some men that I thought had a great head of hair and they looked very young and then when they bent over, I noticed that they were quite thin or balding in mid to crown area. In that scenario I have always thought to myself, "that lucky bastard has a good hairloss pattern-I wish I would lose my hair that way." Who knows, maybe they had a transplant?

 

I think more creedance should be given to the placement of the hairline. The common mistake is that people want it too low. By being slightly more conservative, a lot of grafts can be saved because less realestate needs to be covered. When I told Dr. Shapiro that I wanted to keep my hairline high (conservative) he was happy and stated "Good, that will make things easier and I know that you will be much happier with the outcome."

 

I love this topic because there are so many variables that come into play. I would think that for a true artist of hair transplantation they would enjoy the challenges of a new canvas everyday.

 

Hope this helps.

 

 

NN

[Bill - Seemiller]

I am glad to see that my blog has facilitated an excellent discussion.

 

Clearly there has been much debate about which is better...coverage or density. I personally want both, but since it's not always possible.

 

Ultimately, I think that a natural looking transplant can be achieved in good hands whether one focuses more on density or coverage, assuming the end result ends up leaving the patient with a natural look, following a naturally occuring pattern of hair loss.

 

For example: a NW5 might decide to use all their grafts in the front 2/3 of their scalp and leave the crown alone. Will that necessarily look unnatural? Admittedly it could - however, if the grafts are strategically placed in such a way that leaves the crown area mostly bald - it could leave the patient looking like a natural NW3. This would still be a huge improvement while still looking natural.

 

Continue all with the discussion!

 

Bill

[TheEmperor]

Originally posted by Bill:

I am glad to see that my blog has facilitated an excellent discussion.

 

Clearly there has been much debate about which is better...coverage or density. I personally want both, but since it's not always possible.

 

Ultimately, I think that a natural looking transplant can be achieved in good hands whether one focuses more on density or coverage, assuming the end result ends up leaving the patient with a natural look, following a naturally occuring pattern of hair loss.

 

For example: a NW5 might decide to use all their grafts in the front 2/3 of their scalp and leave the crown alone. Will that necessarily look unnatural? Admittedly it could - however, if the grafts are strategically placed in such a way that leaves the crown area mostly bald - it could leave the patient looking like a natural NW3. This would still be a huge improvement while still looking natural.

 

Continue all with the discussion!

 

Bill

 

Bill,

 

Your HT looks excellent and is a good example of proper planning.

 

It appears that you have maybe 70% density in front transitioning back to about 40% in the back. Everything is connected. It looks like you have mild thinning but the hairline placement looks just right. Your hair appears like it could have occured naturally. You look like a normal 30yo guy.

 

It may be that Dr. Hasson could have gone more dense in the front or lower at the expense of the back, but I agree your/his decision.

[Bill - Seemiller]

TheEmperor,

 

Thank you for the compliments.

 

I am very happy with the decisions I've made as well, of course, with help from my doctors. Dr. Hasson gave me the choice as to whether or not I wanted more density up front or to hit the crown. Upon asking him what he'd do personally (though there is no right or wrong), he agreed with me that he'd probbly hit the crown. I am extremely satisfied with my decision.

 

Bill

[bverotti]

Excellent post Bill, really good stuff.

 

"For example: a NW5 might decide to use all their grafts in the front 2/3 of their scalp and leave the crown alone. Will that necessarily look unnatural? Admittedly it could - however, if the grafts are strategically placed in such a way that leaves the crown area mostly bald - it could leave the patient looking like a natural NW3. This would still be a huge improvement while still looking natural."

 

The coach of Bayern Munich has never had a HT, but he has a very nice conservative hairline, some coverage on top and a bald crown. The guy is pure natural, so any HT resembling his hair is natural since nature does create such hair situation on occasion.

 

Sadly like you say those who are high on the NW scale usually can't have coverage and high density. Very often these guys also have limited donor areas as well.

[calvinmd]

I've come to think that the way the temple areas are handled is absolutely vital if you're gonna have a big bald crown later on.

 

 

It's true that there are natural cases of strong frontal 1/3rds with bald crowns, but how many of them EVER have strong filled temples in front with that crown? Practically none that I ever see in the real world. The few times I see it occurring, the balding seems to be much more of a "diffuse thinning" look in the balding area rather than a harsh transition from hair-to-bald everywhere.

 

When looking at a man straight-on from the front, seeing flat NW#1-2 temples is a visual "no MPB" message, and it creates the subconscious expectation that the rest of the guy's head is gonna be as hairy as the front view. Seeing a huge bald spot in back when the same guy turns his head is so unexpected that it draws attention to itself.

 

 

So what's the moral of the story?

 

IMHO balding crowns and NW#1-2s DO NOT go together. No matter how dense the front may be, a NW#2.5 frontal hairline (or better still, a NW#3) is much better. The subconscious signal you're sending from the front is "baldness is at least possible on my head," and that makes a huge difference when the bald crown shows up.

 

 

-------------------------------------------------

[Bill - Seemiller]

calvinmd,

 

This is why I'm a strong believer in a conservative hairline (including temple restoration) - especially for those who are of a younger age.

 

Hair loss is a progressive condition and simply put, there is no way to predict how much loss one can expect.

 

Bill