How many grafts do I need?
I don’t want the implanted area to be more dense than the rest of the scalp.
I got different answers from few different doctors.
The 2014 hair appears thinner than it is because of flash, being long unwashed, and telogen
effluvium from (hopefully cured) IBS.
Of course I don’t want the implanted area to be more dense than the rest of the scalp.
And I don’t want to lower the widow’s peak, just fill it in a little.
I am L/XL 23/24” hat size.
What might be my density now, implant density, and survival rate?
Thank you, Mark.
Thank you for your question.
You have submitted some photos with a drawing to show where you want your desired hairline
to be.
And in your history described that there is a recent photo where you appear to be thinner
but it was most likely the result of telogen effluvium related to irritable bowel syndrome
and that you want to get an idea of how many grafts you would need to fill the area that
you want to fill.
So you have the 2009 photo and you have the present photo and I understand that you’re
concerned about not having the grafted areas looking more dense than the ungrafted area.
So your question is very logical and very clear and I see how you’re confused because
you’re getting different answers from different doctors.
The hair transplant field is a very interesting field.
There are endless claims made by hair transplant surgeons about their techniques and the number
of grafts being superior to whoever their local competitor is.
And to help our patients understand the realities of hair transplant surgery, we have a very
straight forward process in our practice and I’m going to share with you what we do when
someone like you comes in and help you understand the context of how we do what we do.
First, there’s a desired area to fill so that’s how many graft do you need.
Well, we measure that we measure that with square centimeters.
And when you measure things in square centimeters it becomes very clear that whatever you think
is a little is a lot more than you think.
So you think of that as an expense.
Then we look most importantly at the limitations of the area where the hair will come from,
the donor area.
The donor area is this band of skin hair-bearing that is in the back of the scalp.
And when you think of the baldest man you’ve ever seen someone who is Norwood 7, you know
that there is this narrow band of hair that never goes away.
That is the genetically resistant area that is the true donor area.
And that donor area is the bank that is needed to fill or provide for the expense.
So when you think about in those terms, what other factors are also important?
Well, a critical factor is density.
The same length and width of an area whether you are doing a follicular unit transplant
or a traditional strip method versus an FUE or a follicular unit extraction you are dependent
on a certain limited area and the amount of density, the number of hairs per square centimeters.
So what we do in our practice is we literally draw those same squares, one centimeter squares
or we’ll estimate based on what we typically do which is the strip method and estimate
how many hairs we have available to graft.
Fortunately, most of the time we are surprised to find that there are more hairs than we
originally estimated.
But this brings up a more significant point than just how much you need to fill the area
you desire.
There is a question on what your age is?
How fast are you receding?
When is it possible that you will need another transplant?
So this is the reason why hair transplant is intrinsically flawed in its ability to
make someone happy long-term because people keep having thinning hair.
If you ever see someone at a restaurant who has that “pluggy look” or you meet somebody
and you look at these little hair plugs in the front and you wonder who could have done
that and why does it look so obvious and fake.
Well, most likely that person had existing hair between those hair transplants and if
they were not able to take medical therapy such as Finasteride or they continue to thin
in spite of being on Finasteride or because they just didn’t take it then that left
the hair grafts and that is a critically important factor for you.
When we do hair transplant and again the claims that are made are out of control.
You can only put so many hairs in a square centimeter and they are individually determined
based on the intrinsic anatomy of a particular person’s hair follicle.
So if their hair follicle, the hair shaft and the whole follicular unit is someone who
has thicker hair, wavier hair, and curlier hair then you can’t fit as many in a square
centimeter compared to someone who has finer and thinner hair.
So claims of putting up to a hundred hairs per square centimeter, sixty, eighty whatever
the numbers are get thrown around always has to be tampered with what is the intrinsic
nature of the hair.
You can only fit so many hairs and each hair has to have a surrounding amount of tissue
that will allow for it to grow and survive.
In our practice we actually maximize what we believe is the survivability because we
know that although you can move a lot of hair you can also have a problem with the survivability.
We’ve had patients who’ve come to our practice who had mega session surgeries where
someone did several thousand grafts at one time and they’ve had 90% loss from another
practice were they did not factor in the patients’ blood pressure and the patient ended up bleeding
a lot more or the patient may have had been on blood thinners.
The fact was they put in thousands of hairs and they got barely 10% survival.
So in our practice what we do is we manage blood pressure, we provide IV intravenous
sedation because we’re a full body cosmetic surgery practice and so we do IV sedation.
And we will also use a material called extra cellular matrix to maximize the graft survivability.
Another important point for you is not only about getting the density that you’re looking
for.
It is very difficult to mimic nature’s beautifully density with one transplant when you’re
lowering a hairline.
More often than not, a person who wants a certain amount of density will need more than
one transplant.
So you have to look at that harsh reality of hard numbers.
Factor in the possibility of additional thinning.
So if you haven’t explored ways to manage your thinning hair, let me tell you a little
bit about what we do for our patients when they come in for this type of consultation.
If I see that there is miniaturization and that it appears that they are continuing to
thin which is statistically likely for someone who is already experiencing hair thinning
then we will offer them medical therapy such as Finasteride and Minoxidil.
Unfortunately, a lot of people are hesitant to take Finasteride because of the potential
long-term sexual side effects.
So the majority of patients who come to us actually choose an option we developed called
hair regeneration.
Hair regeneration is the use of extra cellular matrix that is used for wound healing that
we developed a formulation, a method of delivery, a technique to actually long-term reverse
the hair thinning process.
It is essentially using your adult stem cells to repair the flawed mechanisms and the cells
and signals needed for hair growth.
Unfortunately, the questions of what causes hair loss have not been fully answered and
the mechanism of hair growth still remains with missing pieces to the puzzle.
We have a lot of pieces; we don’t know all of them.
This was happened to be a very serendipitous discovery based on an accidental observation
of a man who got a transplant and his thinning hair became thicker.
So hair regeneration is also an option that you can look in to.
My advice would be to really get the hard numbers of density and the amount of hair
that you would need.
And in our practice we actually defer hair transplantation on someone who’s actively
thinning.
We actually treat them first with hair regeneration.
See how much density and volume they get back and then if they need more hair, well, we
can be confident that they won’t continue to thin at least for the 5 year time frame
that we have experienced with hair regeneration that they will be stable and they will be
able to deliver a realistic and natural appearance.
Unfortunately, hair transplant is one of those areas were a person can look good for a while
but if their hair keeps thinning then they can look like they had plugs or they had a
“pluggy look” or they end up being committed and forced to have to do more transplantation.
So you want to make these decisions with a full understanding of what you expect from
the transplant, if you choose to do it what you’re anticipated care plan will be and
look at the alternatives before you just move forward.
Because remember the donor area is a limited area, it’s a limited bank account and you
can’t spend it forever and eventually it will tap out.
So you want to be very very careful about how you strategize your hair loss treatment
plan.
So that being said, I hope that was helpful.
I wish you the best of luck and thank you for your question.