Does FUE Change Donor Area Planning?

Dr. Russell Knudsen (from Australia) wrote in informative article in this months “Hair Transplant Forum International”. Clearly, the ability to harvest the donor area with FUE will be more restrictive in individuals who have more extensive balding patterns (Class 5, 6 and 7 patterns of balding). The donor area around the sides and back of the head reflect 25% of the original total hair count on the head (I call it my 25% rule). If one targets somewhere between half or 2/3rds of the follicular units found in the donor area, as the maximum safe yield for FUE over time, then for Caucasians with average hair density (100,000 hairs on their head or 50,000 follicular units in the permanent zone) might be able to safely harvest as much as between 6,250 (half) or 8,250 (2/3rds) from the 12,500 follicular units in the permanent zone (25% rule).

In those individuals with higher densities than 100,000 hairs on their head, the harvestable follicular unit numbers may safely go higher, while in the typical Asian, for example with lower hair densities (80,000 hairs on their head or 40,000 follicular units), the donor area would contain only 10,000 follicular units. With half of the Asian’s 10,000 follicular units harvested, that leaves 5,000 follicular units behind (this reflects a calculation of 25% of the birth hair follicular unit numbers which are permanent). I believe that extracting between one out of every two follicular units from the permanent zone may be pushing the limit on people with low density hair.

There may be reasonable limits for a typical Asian based upon hair density (we calculate hair density on every patient undergoing hair transplant surgery). To complicate matters, Asian follicular unit hair counts average less than two hairs per follicular unit, so to get out an average of two hair FUE grafts, it takes more follicular units to yield an average of two hair FUE grafts. Asians (or Caucasians with low hair density) who have a high number of FUEs will, in my opinion, be thin looking around the back and sides of the head. I have seen some Asians with significant track marks from the punch scars created by FUE, particularly when the harvesting numbers are high and the remaining donor hair is significantly lessened.

Many doctors are taking hair from the non-permanent area to give the patient the benefits of more hair in the transplant; however, this may spell disaster for the patient who develops more extensive balding (suggested by Dr. Knudsen). Hair taken from the non-permanent area will be lost with aging and/or advancement of the balding patterns. Over zealous FUE beyond the permanent zone, has long term consequences for some patients and they must be warned. I have seen some patients who’s balding had accelerated from multiple FUE procedures and have loss hair in areas where FUE grafts were taken while leaving visible scars.

I want to raise blood supply issues here as I have seen one patient already who had received 6700 FUE grafts in two sessions and lost more hair in the permanent zone than was removed by the surgeon during the FUE. I actually counted the grafts and the hairs on the head and had done density studies on him before another surgeon did surgery on him. When FUE numbers are pushed, this patient’s findings suggested vascular compromise may have occurred impacting the remaining hair in the donor area. I have heard, second hand, that at the last ISHRS meeting some cases of necrosis have appeared in the donor area when too many FUEs were done, possibly too close together. I don’t believe we really understanding the complications of large FUE sessions, or that doctors are not reporting their complications out of fear of professional ridicule and/or malpractice risks, all of which may become a factor in the long term future of this surgery. As we do many FUE cases in our practice, we are not anti-FUE; however, aggressive FUE megasessions in the wrong hands could be a problem.

In conclusion, “do FUE surgeries change donor area planning”, the answer is YES. FUE will impact long term planning and may impact strip surgery in future surgeries. Low density donor areas, resulting from FUE, make for less donor hair for a strip surgery, which will only make any scarring more visible as the hair is cut short.

Megasession vs Multiple Smaller Sessions?

Dr Rassman

Let’s assume someone’s donor area may yield, say, 5000 grafts using the strip technique. Is it better to have 1 mega session or 3 smaller ones? Is the yield better when cutting the skin only once (or twice) with megasessions compared to 3 or 4 times with in smaller operations?

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I have always believed that less surgery is better than more surgery in people with more extensive balding patterns. If you can get 6,000 grafts in two sessions, why go for 6 sessions of 1000 grafts each? If the density and laxity allow for it, most of my patients prefer to have one larger session and hopefully just be done with the surgical process quicker. This means in a practical sense that 6-7 months after the first session of 3000 grafts, you can see results which will impact your ability to style your hair.

Alternatively, I can make an argument against the large session. Multiple FUE procedures or smaller strip sessions have a relatively short recovery time, but for FUE, the shaving of the donor area can be a problem unless you elect to keep your hair short, so regrowth of the donor area usually occurs in about 10 days. Smaller strip cases will have their donor scar covered by the existing donor hair.

Incremental surgeries have really no downside other than the length of time from the point you start to the time you finish. It is possible that more surgeries could give you wider scars, but this has never been studied with any direct comparison. Few patients approach me with a desire for multiple smaller surgeries and prolonged benefits, as they want the benefits quickly and would like to say goodbye to me and the hair transplant process altogether. I am, however, open to performing multiple smaller surgeries.

Tags: megasession, hair transplant, surgery, hairloss, hair loss, hair restoration

FUE Megasessions?

if this is answered in your blogs forgive me and just send a link. i am clear i want a ht. i have done much research and am still meeting with docs. i can do in thailand, uk, usa. my one reservation has been the scarring and after effect, plus temporary nerve damage on the head. after realising FUE could be done in a megasession i feel this is it for me, (told i need 3-4000 hairs/grafts). as i research so many are careful, sceptical of it. i have come across you (dr. Rassman) and dr. cole. i understand a skilled physician is necessary. will FUE of 3-4000 grafts megasession handle it for me (norwood 3v to a 4)? do you recommend it more than strip or not? is it a very viable option? with dr. cole or you? thank you.

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A skilled physician is necessary for any surgery you have, and one that specializes in the cosmetic surgery you’re looking into is absolutely something I’d recommend. If you’re asking me whether you should go to me for your hair transplant or go to another surgeon, well, I think the answer would be pretty obvious. However, I cannot recommend surgery options for you at this point, as I have not examined you or know of your medical history. Everyone is different and all surgery has its risks and benefits (FUE vs strip, etc).

What I can tell you is that I have never performed a 3000 to 4000 graft follicular unit extraction (FUE) procedure in one session. I think I can say this with some authority, as I was the one who introduced the FUE technique to the international community in 2002, but an FUE procedure of that size will likely lead to a higher transection rate due to physician fatigue.

I realize it has been 8 years since the technique was introduced and other physicians have performed and tried to perfect the technique, but there are factors that the general public do not know of in such surgery. To the general public, FUE sounds slick and the best of all worlds (you get hair with minimal scarring). But there are some thing you need to look out for. Please read about these in my post from a few years back — What Doctors Don’t Want You to Know About FUE.

Tags: fue megasession, hairloss, hair loss, hair transplant, fue, follicular unit extraction

My Hair Transplant Is Growing At an Unnatural Angle (with Photo)


Hello Dr. Rassman,

Thank you so much for the service you provide the public with this site. It must be alot of extra uncompensated work for you, I appreciate it.

I got a 1300 hair graft about 9 months ago to the area that I roughly outlined in red (on both sides of my head of course, I am only showing one side). As you can see it is growing at nearly a 90 degree angle on my head whereas my natural hair falls forward. Even though I cut my hair at the same length, the transplanted area looks twice as long because it is growing directly ‘up’. My two questions are this: 1. Is this a lack of skill on the doctors part that it is growing at an unnatural angle? and 2) if I keep trying to comb it forward can you gradually adjust the natural angle of the hair so that it matches with the rest of my hair as to the angle that it grows (or will the transplanted area permanently be at odds with my natural hair growth angle)?

My doctor recommends a second procedure because as you can see the transplanted area looks quite thin. I am 26, do you see any concerns with having a second procedure done with this doctor, or do you sense a lack of skill and I should look elsewhere? I have minor thinning in the crown area as well, but I do not plan on transplanting anything to that area. I have been on propecia for 9 months, and while it has not totally regrown the crown area, I am hoping that it will prevent further loss in that area.

Many thanks, and feel free to post the picture.

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Thank you for permission to post your photo. Please click the photo to enlarge.

You are correct. It seems your hair was transplanted at different angle than your native hair. The surgeon planning for the correct angle and direction of hair is a very important factor in a hair transplant procedure. Unfortunately, this is very difficult to correct and relatively impossible to reverse. Your transplanted hair will always grow in that unnatural direction. One of your options is to have another transplant procedure and make sure that the new transplants are in the correct direction to “blend” in with your hair.

With respect to a second surgery with the same doctor, you need to be able to trust the doctor before having any procedure. Doctors are human beings and they can make mistakes or misjudge the many decisions that are before them in a treatment plan. If you and your doctor have a good trusting relationship, I am sure he/she will see the difference in angle and your concerns and will be more than happy to accommodate accordingly. The key here is to directly discuss this with your doctor first, and then make decisions on the value of the doctor/patient relationship.

Tags: hairtransplant, hair transplant, photo, angle, surgery, procedure, unnatural, hairloss, hair loss

Small FUE Procedures Every Couple Weeks — A New Marketing Gimmick or a Reality?

A patient came to see me last week asking about multiple, short Follicular Unit Extraction (FUE) procedures for his frontal hairline, eventually totaling 1400 grafts. He is a busy attorney and wants to have his hairline restored, but did not have the time to get it done. He went to a doctor who told him that he could come in after court every 2-3 weeks, and get 200 FUE grafts placed into the frontal hairline. As an attorney who does not trust anyone at first glance, he came to me for a second opinion. Money was not an issue, but the charge would be $2,000 for each procedure.

I told him that this did not seem like a good idea to me. If he had 1400 grafts total over 7 sessions just two-three weeks apart, the hair would fall out between the surgeries and the surgeon could not see where the previous transplants were placed, therefore possibly causing damage. I also believe that 7 surgeries are not as good as one, but if he insisted on multiple surgeries, he must wait 7-8 months between the surgeries so that the previous grafts would not be damaged. It is possible that two surgeries spaced 2-3 weeks apart (one on the right side and one on the left side) might be able to harvest 500-700 grafts through an FUE surgery, but he would have to keep his hair long.

For more on FUE / FOX Procedure, please see:

Tags: fue, hairloss, hair loss, hair transplant, hairtransplant

Large 5000+ Graft Transplants

I read about megasessions of 5000 or more grafts. Particularly from a Canadian group. Yet unless the average Canadian hat size is larger, that is near impossible unless they are doing it on the graft dissection end of things. How can one doc get so much more hair then others??Larger heads, larger incisions??

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Large sessions, really large ones, were defined by me in 1993-4 timeframe when I reported first breaking 2000 grafts/session, then 3000, and finally in early 1994 I reported my first of many 4000+ graft sessions. These are not typical. First, the surgical team must be trained in doing large sessions with fast, efficient cutting and placing. The following points must be available for the surgery to be successful:

  1. The sessions should not take more than 8 hours, for beyond that time, the grafts out of the body that are awaiting placement produces reduced graft growth.
  2. The surgeon must know the nuances of prolonged anesthesia without increasing the risks to the patient.
  3. The patient’s scalp laxity must be very loose so that a wide strip can be taken safely (often these strips measure greater than 2cm in width and 10 inches in length).
  4. The patient’s density must be high (50% higher than normal densities).
  5. And as you said, the head should be a larger size to yield wider and longer strips.

Large sessions are no more risky than smaller sessions, but the above criteria must be met or the yield would not be there. My record number of grafts in any one session to date is 5800 grafts. I remember that patient well, because had his balding pattern been more advanced, I would have gotten 10,000 grafts from him with ease. His density was twice average densities, his head was larger than normal, his scalp was loose (actually, very loose), he was young and healthy and we completed the surgery in 7 hours.

Good question and thanks for asking it.

Tags: hairtransplant, hair transplant, largesession, session, densepacking, megasession

Wound Problems After Hair Transplant

Dr. Rassman:
You recently responded on 1-9-06 on this website to a male that had some questions regarding the possibility of taking a jacuzzi soon after having a hair transplant. He had then undergone hyperbaric therapy and succesively (evidently) underwent hyperbaric therapy. You asked him to respond as to whether or not the hyperbaric therapy allowed him to possibly avoid the approx 60 days hair loss that typically follows such surgeries.I recently underwent a 2 day megasession of 3800 grfts. I had 3 small hair transplants 10, 9 & 7 years ago (Only 300, 300 & 400 grafts then). The right side donor incision was very tight and when the stiches were removed – huge opening 1″ x 2″ now. Hyperbaric Candidate?

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The posting you’ve referenced can be found here: Can I Go in a Hot Tub Days After a Hair Transplant?

One of the challenges of megasessions (you had 3800 grafts) is to harvest large numbers of grafts safely. The physicians must make judgments with regard to balancing an aggressive approach to harvesting hair and complications (safety issues) that will put you at an increasing risk. This is actually true for any harvesting process of almost any number of grafts (even small sessions), but it is particularly the case with megasessions. In your case, it is not a long stretch to assume that this delicate balance was tipped such that a tight scalp produced a wound problem because, in hindsight, the harvested strip may have been too aggressively pursued.

The tight scalp and the wound problems that occur as a result, are what has brought a focus on donor wound scarring. In people who have had three transplant sessions (as you did) tighter scalps are often present. Most of the time, the desire of the surgeon/patient to get large enough quantities of hair to cover areas of high demand (recipient area), has been the cause of the scarring problems. The actions and techniques used by the surgeon may compound this problem. The amount of hair (scalp) that is safe to move, depends upon the ‘looseness’ of the scalp, the density of the hair in the proposed strip of scalp that is removed, and the amount of scalp that is actually removed. The more scalp that is removed (in the patient with a tighter scalp), the greater the risks, such as what happened to you. When wound problems exist, they start off with unusual prolonged pain along the wound edge and develop a pink, purple, or dark color of the skin (indicating possible vascular problems to the skin). The darker the color, the worse the risk and the worst short term risk (that of gangrene of the skin). The long term risk is of hair loss extending back from the wound for a distance of one – two inches above and below the tight parts of the wound occurs not infrequently when a wound is too tight. What will happen to you will be determined by the degree of blood supply compromise brought on by the tightness. If these problems are only mild, hair loss often follows. The hair will generally, but not always, return in 4-6 months (along with the timing of the growth of the transplants in the recipient area). You will know the full impact within approximately 6-8 weeks, but the risks of gangrene should have been passed in a week or two. Patience is a virtue here and a good communication with your doctor is critically important to deal with any and all of your concerns. Ask your doctor about hyperbaric oxygen as well.

To avoid this problem, the experience of the doctor is important (especially when it comes to safety in these megasessions). Decisions made at the time of surgery are many. Sometimes I get a feeling from patients that hair transplantation is all about price so discount shopping is very common. But is a megasession in the hands of a very experienced doctor equal to the same in a doctor with much less experience? That is the question! The answer is clearly that doctors are not equal, even if prices are.

Now to get to your question: I have no experience with hyperbaric oxygen in situations like yours. Theoritically, it might help, but timing may be everything and delays in administering this therapy along with frequency will certainly work to your disadvantage if this modality was to work at all.

Washing Scabs One Week After Surgery

I just had a FU mega-session 7 days ago. I have been very careful with daily washing of the 3000+ grafts that I had. I have been washing and rinsing only through a washcloth. I have been using the post-op copper peptides etc. I have been so careful that I have not really lost any of the scabs or crust associated with grafts. I even have been sleeping with moistened guaze under a surgical cap at night.

I am needing these (scabs etc.) to be gone so that I can return to work. In a previous posting you mentioned advocating “aggressive washing”. How should I be washing the grafts at 7 days post-op, in order to expedite the scab removal. I haven’t been picking at them but maybe I have been too careful…….Please help.

Your sight and advice are very valuable and I thank you for them……

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Washing is something that must be started at the time of the surgery so that when the patient leaves the surgical suite, the recipient area should be clot and blood free. A good thorough washing the morning following the transplant is critical as it will impact the appearance on all subsequent days. Good washing protects most people against folliculitis and infections of the donor wounds so daily or twice daily washes are critical. There is a washing art form, one which we teach our patients at the time of the surgery and on the day after, when most patients return for a hair wash administered by us. After 5-7 days, the scabs should be gone. If they are present to a significant degree, then you must be gentle with them for if you pull one out, the graft may come off with it. Mostly, if the wounds are small and the scabs are already shedding, you can wet your hair, cover it with a good conditioner when wet, leave it on for 10-15 minutes to allow the scabs to soak up the moisture, and then wash your hair using your finger tips to gently try to get the scabs off. Dr. Robert Bernstein and I just wrote a scientific paper on this to show that when the scabs are off, the grafts are safely anchored. The scabs anchor to the grafts, so if you pull on a scab the graft can come out with it. If you follow the washing technique I just outlined the scabs should come off in a day or two, providing that they are not anchored too tightly to the scalp.

Size of FUE Procedure?

I have read the stories at your site and I think its a great idea to make this forum.

My question is: I am having a FUE transplant in 2 months, and have agreed to have 1500 grafts. How many grafts is it possible to move? Maybe it is an individual answer for each person. My situation is that i have had a strip transplant 7 years ago. It was okay but left me with the traditional scar in the back. I am not bald but my hair is thin from front to crown and now I will have a fill in with 1500 grafts if there are enough available, as my doctor says.

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FUE in the 1500 graft range is a big procedure. Follicular Unit Extraction (FUE) is a procedure you must be careful of when considering a hair transplant. A graft removed by FUE has a risk of being damaged when it is extracted. That damage can come from:

  1. grafts that have many transected hairs when they are taken out, producing fewer hairs removed
  2. grafts that are buried inside and left behind, which can cause infections and foreign body reactions
  3. grafts that lose the fat that surrounds them, making them vulnerable to fast drying or growth center damage which will impact graft survival and hair growth

More and more doctors are performing FUE, but few have the skills to do them with a very high hair (not graft) yield. For example, if you take out a 4 hair graft, but three hairs are transected and one comes out, does that reflect 100% success or 25% success? This is a very important focus for the individual who is purchasing FUE, as some doctors call such a graft as 100% successful because one hair came out, as it would have in a one hair graft. I would call it 25% success and a kill of 75% of valuable donor hair. Whatever doctor you are considering, please check this point out by asking for a direct answer to this.

At a meeting in the past year, a series of doctors demonstrated their skills in FUE and each had claimed expertise in the art, but alas, only one had good hair yields. This is no surprise to me, no surprise at all. Some doctors claim expertise with limited (or no) experience, and some claim experience without any audit of hair yield in place for each procedure. When I published the first paper ever published on this technique, a doctor who had built no significant presence in the field announced expertise within 60 days of my publication, announcing to the world that he invented the procedure. I remember him well, because he called me to ask me how to do the procedure and I gave him advice on some of the details he wanted to know. When I read about his self-declared expertise, I felt sorry for the patients who would fall into the “spider’s web”.

For more information about FUE, please see:

Megasession Results (with Photos)

What does a 3000 graft operation look like in a person with a Class 6 Norwood balding pattern, fine hair and moderate contrast between hair and skin color?

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The below patient is in his late 60s and had one hair transplant procedure of 3,164 grafts. The grafts were placed to cover the entire balding area. In helping you understand the issues related to fullness, the area covered placed about 6000 hairs (in 3,164 grafts) in an area that originally had 50,000 hairs. That means that what you are looking at about 12% of his original hair density (before he went bald). Clearly, the math points out that a return to his original fullness is not possible. Many times people ask me how many grafts one needs to get a full head of hair. The answer to that question depends upon the thickness of the hair shaft, the character of the hair (straight or wavy), the color contrast between hair and skin color (the lower the contrast the better) and the size of the bald area being treated. I have placed 3000 grafts into an area 1/4 the size of this man’s bald area and the results were a much fuller appearance.

There is a general misconception in the hair restoration community that one can tackle a man with this degree of balding and replace the fullness to his original look in one session with as few as 1500 grafts. Many unethical doctors make that representation and I find it difficult to ‘compete’ with a doctor who promises a full head of hair with half the number of grafts I showed here (probably at half the price because of fewer numbers and salesmen that promote such misconceptions). I try to show how important it is for today’s buyer to understand just what he is buying and what he can expect. Be careful when a doctor shows you just a single view of a result, places the photo in a shadow, and does not really cover the entire transplanted area. That is the reason we have open house events monthly and have been doing them for 14 years. Visitors can see and interview patients, examining just what they are going to get without tricks of photography or slick salesmen to tell you what you might want to hear, true or not. With that said, the man shown below felt transformed in just the one procedure. He wanted a second session to increase the fullness further and after these pictures were taken, a second procedure of 3000 more grafts were done with a similar distribution, though it is far too early to show the results of that procedure. Please click each photo to enlarge.

The 1st set (below) are the before photos.




 

The 2nd set (below), are the after photos, taken 10 months after one procedure.