Is it Safe to Implant 6,000 Grafts in 2 Days Using FUE?

Is it Safe to Implant 6,000 Grafts in 2 Days Using FUE?

Q: Is it safe to implant 6,000 grafts in 2 days with an FUE procedure? — L.P. ~ Port Washington, N.Y.

A: A 6,000-graft procedure would be a very large hair transplant. Transplanting this many grafts at once would necessitate grafts being placed very close together. In this situation, the blood supply may not be adequate to support the growth of the newly transplanted grafts.

Another reason for concern is that when harvesting, FUE yields about 20 grafts/cm2. A 6,000-graft procedure would require 300 cm2. Since the donor area is about 30 cm long, this would require a donor height of 10 cm, clearly extending beyond the permanent zone of the scalp of most patients.

Posted by

Dr. Bernstein Proposes Improvements to FUE Hair Transplant Procedures

Robotic FUE has improved Follicular Unit Extraction by automating what has been a labor intensive and often inexact manual procedure. It is the latest in a long line of improvements made to hair restoration procedures that lead to better results for hair transplant patients. Dr. Bernstein’s recent publication in Hair Transplant Forum International improves the FUE procedure even further, whether performing follicular unit extraction with the FUE robot or by hand.

In his article, Dr. Bernstein suggests two techniques to enhance the FUE procedure. First, he recommends that surgeons create recipient sites prior to extraction, in order to decrease the time grafts are in their holding solution outside the body. Second, he suggests adding time between site creation and graft harvesting and placement, to allow recipient site healing to progress.

Pre-Making Recipient Sites

As is discussed in the full article (which is available for viewing and download in our Medical Publications section), by making recipient sites first, the time grafts are out of the body will be reduced.FUE procedures lend themselves to easily reversing the normal hair transplant sequence of graft (strip) harvesting followed by dissection and site creation.

These “pre-made” recipient sites will also exhibit less bleeding than newly created sites and will exhibit the stickiness that makes older sites easier to place grafts into with less popping (a common source of graft injury). Besides allowing the placing step to proceed more quickly, pre-making sites will reduce the risk of mechanical injury inherent in repositioning elevated grafts.

After Site Creation, Add Delay between Graft Harvesting and Placement

While Dr. Bernstein acknowledges the expediency for the hair restoration physician, as well as the comfort of the patient in a single-day session, he suggests that, to facilitate growth after a transplant, multiple-day procedures should be considered in large hair transplant sessions that involve the placement of thousands of grafts.

In conclusion, these two modifications -— pre-making recipient sites and adding a delay before graft placement -— to the FUE procedure can potentially contribute to better growth due to easier, less traumatic graft insertion, a shortened time “out of body,” and the creation of a more fertile bed for the implanted grafts.

View the full article to read details about these and other potential advantages of pre-making recipient sites

Posted by Robert M. Bernstein M.D.

Do You Use Megasessions or Very Large Graft Sessions In Your Hair Transplant Procedures?

Q: Some surgeons are doing hair transplants using 5,000 to 6,000 grafts in a single surgery. Looking at the cases in your photo gallery, it seems like your hair transplants involve many fewer grafts per surgery. Do you do such large graft numbers in a single hair restoration procedure? — H.P., Cranston, R.I.

A: The goal in surgical hair restoration should be to achieve the best results using the least amount of donor hair (the patient’s permanent reserves) and not simply to transplant the most grafts in one session. In my opinion, although large sessions are very desirable, the recent obsession with extremely large numbers of grafts in one session is misplaced. The focus should be on results.

For example, I would prefer to have full growth with a properly placed 2,500 – 3,000 graft hair transplant session than partial growth in a 5,000 graft session. Of course, the 5,000 graft session will look fuller than 2,500 grafts but, in my experience, never twice as full, and never as full as two 2,500 graft sessions.

The ability to perform large sessions is possible because of the very small recipient sites needed in Follicular Unit Transplantation (FUT). It is one of the main reasons that we developed this procedure in back in 1995. See the first paper on this subject: Follicular Transplantation.

However, like all good things, the technique loses some of its advantage when taken to extreme.

In “very” large sessions, the long duration of surgery, the increased time the grafts are outside the body, the increased amount of scalp wounding, risk of poor growth, wider donor scars, placing grafts where they are not needed, sub-dividing follicular units, and the decreased ability to plan for future hair loss, can all contribute to suboptimal results. These problems don’t always occur, but the larger the session, the greater the risk. Therefore, it is important to decide if one’s goal is simply to transplant the maximum amount of hair that is possible in one session, or to get the best long-term results from your hair restoration.

Follicular Unit Preservation

One of the most fundamental issues is that doctors using very large sessions are not always performing “Follicular Unit Transplantation” and, therefore, in these situations the patients will not achieve the full benefit of the FUT procedure. Although doctors who perform these very large sessions take the liberty of calling their surgery “Follicular Unit Transplantation,” in actuality it is not, since naturally occurring follicular units are not always kept whole. The procedure is defined as follows: “Follicular Unit Transplantation is a method of hair restoration surgery where hair is transplanted exclusively in its naturally occurring, individual follicular units.” (see Hair Transplant Classification)

By preserving follicular units, FUT maximizes the cosmetic impact of the surgery by using the full complement of 1 to 4-hairs contained in naturally occurring follicular units. A whole follicular unit will obviously contain more hair than a partial one and will give the most fullness. Keeping follicular units whole also insures maximal growth since a divided follicular unit loses its protective sheath and risks being damaged in the dissection.

It can sound impressive to claim that you performing very large hair transplants, but if the large numbers of grafts are a result dividing up follicular units, then the patient is being short-changed. The reason is that, although the number of grafts is increased, the total number of hairs transplanted is not. A 3-hair follicular unit that is split up into a 1-hair and 2-hair micro-graft will double the graft count, but not change the total number of hairs actually transplanted. In fact, due to the increased dissection, more fragile grafts, and all the other potential problems associated with very long hair transplant sessions, the total number of hairs that actually grow may be a lot less. Please look at the section “Limits to Large Hair Transplant Sessions” on the Graft Numbers page of the Bernstein Medical – Center for Hair Restoration website for a more detailed explanation of how breaking up follicular units can affect graft counts.

Donor Scarring

Since there are around 90 follicular units per cm2 in the donor scalp, one needs a 1cm wide by 28cm long (11inch) incision to harvest 2,500 follicular units. A 5,000 follicular unit procedure, using this width, would need to be 22 inches long, but the maximum length one can harvest a strip in the average individual is 13 inches (the distance around the entire scalp from one temple to the other).

In order to harvest 5,000 grafts, one would need 5,000 / 90 FU/cm2 = 55.6cm2 of donor tissue. If one takes the full 13 inch strip (33cm), then it would need to be 1.85 cm wide (55.6cm2 / (33cm long) = 1.85cm wide) or 1.85/2.54= ¾ of an inch wide along its entire length. However, one must taper the ends of a strip this wide (you can’t suture closed a rectangle) and, in addition, you can’t take such a wide strip over the ears. When you do the math again, it turns out that for most of the incision, the width must be almost an inch wide, an incredibly large amount of tissue to be removed in one procedure.

This large incision obviously increases the risk of having a wide donor scar – probably the most undesirable complication of a hair transplant. Needless to say, very large graft counts are achieved by sub-dividing follicular units rather than exposing the patient to the risk of an excessively large donor incision.

Popping

There are other issues as well. Large sessions go hand-in-hand with very high graft densities, since you often need these densities to fit the grafts in a finite area. The closer grafts are placed together, the greater the degree of popping. Popping occurs when a graft that is placed in the skin causes an adjacent one to lift-up. When a graft pops (elevates above the surface of the skin) it tends to dry out and die. Some degree of popping is a normal part of most hair transplant procedures and can be easily controlled by a skilled surgical team, but when it is excessive it can pose a significant risk to graft survival.

The best way to decrease the risk of popping being a significant problem is to not push large sessions (and the associated very dense packing) to the limit. In a patient’s first hair restoration procedure, it is literally impossible to predict the likelihood of excessive popping and once a very large strip is harvested, or the recipient sites are created in a very large session, it may be too late to correct for this. In addition, popping can vary at different times during the procedure and in different parts of the scalp adding to the problem of anticipating its occurrence.

Even if the distribution of grafts is well planned from the outset, a very large first session may force the surgeon to place hair in less-than-optimal regions of the scalp when popping occurs. This is because the surgeon must distribute the grafts further apart and thus over a larger area to prevent popping.

Blood Flow

Particularly where there is long-standing hair loss, the blood flow to the scalp has decreased making the scalp unable to support a very large number of grafts. This is not the cause of the hair loss, but the result of a decreased need for blood when the follicles have disappeared. In addition, persons that have been bald for a long time often have more sun damage on their scalp, a second factor that significantly compromises the scalp’s blood supply and may compromise the follicles survival when too many grafts are placed in one session. As with popping, the extent of photo-damage, as seen when the scalp gets a dusky-purple color during the creating of recipient sites, often only becomes evident once the procedure is well under way.

In the healing process following the first hair transplant, much of the original blood supply returns and this makes the scalp able to support additional grafts (this is particularly true if one waits a minimum of 8-10 months between procedures). This is another reason why it is better to not to be too aggressive in a first session when there is long-standing baldness or significant photo damage and where the blood supply may be compromised.

Limited Donor Supply

Another issue that is overlooked in performing a very large first session is that the average person only has about 6,000 movable follicular units in the donor area. When 5,000 grafts are used for the 1st procedure there will be little left for subsequent sessions and limit the ability of the surgeon to increase density in areas such as the frontal forelock or transplant into new areas when there is additional hair loss.

Conclusion

There are many advantages of performing large hair transplants, including having a natural look after one procedure, minimizing the number of times the donor area is accessed, and accomplishing the patient’s goals as quickly as possible. However, one should be cautious not to achieve this at the expense of a wider donor scar, poor graft growth, or a compromised ability to plan for future hair loss.

Achieving very high graft numbers should never be accomplished by dividing up the naturally occurring follicular units into smaller groups, as this increases the risk to the grafts, extends the duration of surgery, increases the cost of the procedure (when charging by the graft) and results in an overall thinner look.

For further discussion see:

The last section in Graft Numbers titled “Limits to Large Hair Transplant Sessions”
Commentary: How large should hair transplant sessions be?

Posted by Robert M. Bernstein M.D.

Dr. Bernstein Debates Large Graft Hair Transplants At 1998 ISHRS Meeting

Follicular Unit Transplantation (FUT) was first introduced to the medical community by Dr. Robert Bernstein in his 1995 publication “Follicular Transplantation.” Dr. Bernstein presented this paper at the Annual Meeting of the International Society of Hair Restoration Surgeons the following year. However, the procedure initially met with great resistance by hair transplant community and for the next three years, only a handful of physicians were actually using this new technique. That all changed in 1998.

At the 6th Annual 1998 Meeting of the International Society of Hair Restoration Surgeons held in Washington, D.C., Dr. Walter Unger (defending the “old guard”) debated Dr. Bernstein (representing this new technique) in front of an audience of over 450 hair restoration surgeons from around the world. Dr. Unger took the position that large grafts still had a place in surgical hair restoration, particularly for creating density. Dr. Bernstein took the position that the new procedure of Follicular Unit Transplantation could create that density while at the same time achieving a completely natural look – something large graft procedures were incapable of doing. He argued that the versatility and naturalness of Follicular Unit Transplantation rendered the older procedures obsolete.

Follicular Unit Hair Transplantation clearly won the day… and the rest is history. Within three years of this debate, there were hardly any doctors left in the United States still performing large-graft hair transplant techniques. A review of their discourse appeared in Dermatology Times.

Excerpts from the debate with Drs. Unger and Bernstein taken from presentations at the annual meeting of the International Society of Hair Restoration Surgery held in Washington, D.C., 1998.

Is There Still a Place for Standard Grafts in Hair Restoration Surgery?

Position: YES

Dr. Walter Unger

You have to use the hair transplant technique that will give you consistently good results. I can consistently produce very natural-looking results regardless of the type of grafts that I use. I have many patients come back who report that even their hairstylists can’t tell that they have had transplants.

It’s not that I don’t like follicular units or have a thing about big grafts; I know that all of these techniques can yield good results. I object to the “absolute” rules presented by speakers at hair restoration meetings, on the Internet, or in advertisements in order to promote one particular concept.

Of course, you can produce 80 hairs per square centimeter with Follicular Unit Transplantation, and you get good results. However, you shouldn’t remove any of the other graft options, including standard grafts, from your armamentarium.

This is what is wrong with our profession right now: there is too much “irrational exuberance.” If you can find something that works well in your hands, then use it, but do not tell other people that it is the only way they can do things.

There are costs to follicular unit-only hair transplantation that must be recognized. I get less density with follicular units than I can get with a session using several different graft sizes. Given, thin is often appropriate; you don’t want to use up all of your donor hair frontally if you have a limited or poor donor-recipient area ratio. You also don’t want to use it up in a young man.

However, there are some people who can well afford the donor hair and want great density. In these individuals, mixed grafts are the best option in my hands.

Furthermore, there is more tissue handling with follicular unit transplantation during both preparation and insertion of the grafts. A larger number of grafts have to be transplanted, and they have to be densely packed if you want a dense enough result per session, compared with standard grafting.

Follicular unit grafting also risks the loss of hairless follicles. You can lose up to 13% of follicles that are in the resting telogen phase. Even if you can see these hairless follicles, and I’m not sure that you can, technicians are not looking for them when they are slicing up donor tissue into follicular units.

Admittedly, you have to be an extraordinary surgeon to get good results with large grafts at the hairline. However, when I use larger grafts, I use them in a limited area posterior to the hairline zone, which is always created with micrografts and minigrafts anteriorly as well as posteriorly; on either side of the larger grafts; and in areas of existing hair that is likely to be lost with the progression of male pattern baldness.

Position: NO

Dr. Robert M. Bernstein

Finally, after 40 years, standard grafts are on the defensive.

Standard grafts exhibit a callous indifference to human tissue. Standard grafting causes significant damage to the donor area through the larger recipient wounds. They always require a “cover-up” using smaller, more appropriately sized grafts.

Proponents of standard grafting claim that large grafts are needed for density and that large grafts avoid the loss of telogen follicles.

They also lament the psychological toll of long hair transplant sessions using small grafts but ignore the effects of a protracted course of small multiple surgeries.

These hair restoration surgeons attempt to impress you with fancy terms like “maximum density” and dazzle you with hair counts approaching 200 hairs per square centimeter.

But traditional grafts often cause the scalp to feel unnatural and have an unnatural look when wet, when the hair is seen at different angles, or when the hair is not perfectly groomed. Other dangers include decreased perfusion after healing, an unnecessarily large number of procedures, and long-term problems with hair distribution.

All of us can achieve high density, but the final density is determined by the amount of hair moved, rather than the size of the grafts. Density is a somewhat misleading term since a transplanted density that approximates 50% of the original hair density is indistinguishable from one’s original hair.

Regardless, you can achieve as much density as you want with follicular transplantation while maintaining a totally natural look.

Moreover, telogen hairs are not necessarily lost when properly dissected during follicular unit harvesting because they often are part of a follicular unit that has visible hairs.

The risk therefore of any of them being lost is negligible, particularly if the dissection is performed with care.

The future of hair transplantation lies in the ability to preserve the blood supply and minimize scarring in the recipient area.

When standard large grafts are used centrally, multiple hair transplant sessions are required and there is a possibility that the blood supply can be compromised, resulting in poor growth and “doughnuting,” a condition where the hair in the center of large grafts does not survive.

Hair survival in larger grafts is highly exaggerated; doughnuting and other evidence of poor graft survival are evident regardless of technique.

Large grafts are very inefficient, seldom grow at 100%, and require a “screening” population of micrografts and minigrafts to look natural. As a result, they rapidly deplete donor supply.

Regardless, the primary reason for the decline of standard graft use is that even the best of 4-session standard graft cases appear pluggy upon close inspection. The rationale for using standard round grafts has been to achieve maximum density. However, appropriate density can now be achieved with a hair restoration procedure that looks totally natural and avoids the problem of these larger grafts. If doctors had the insight to use small grafts when hair transplantation first began in the 1950’s would we even be discussing the use of the larger standard graft procedures today?

Posted by Robert M. Bernstein M.D.

Browse Hair Restoration Answers by topic:

▲ Top of Page

How Large Should Hair Transplant Sessions Be

Is it Safe to Implant 6,000 Grafts in 2 Days Using FUE?

Dr. Bernstein Proposes Improvements to FUE Hair Transplant Procedures

Do You Use Megasessions or Very Large Graft Sessions In Your Hair Transplant Procedures?

Dr. Bernstein Debates Large Graft Hair Transplants At 1998 ISHRS Meeting

Address

Phone

Clinic Hours

Services

Contact Us

Address

Phone

Clinic Hours

Services

Contact Us

Directions