Category: Hair Transplantation

A man of Chinese descent came into the office this week. He had a Norwood Class 4A balding pattern (see art below). He told me that in surfing the Internet, he found and contacted a couple of doctors, sending pictures of his balding pattern to them via email. Conversations with both doctors suggested that he receive 4000-5000 grafts. First of all, he is an Asian, which means that his average density should be around 1.7 hairs per mm square (Caucasian average is 2.1) and he was probably born with 80,000 hairs on his head. But when I measured his density, it was low for a Chinese man, measuring 1.3 hairs per mm square (total hair count on his head before he lost hair was in the 60,000 range). His hair was black and straight with an average weight. His skin laxity was average.

To get 4000-5000 grafts, it might require more than a 3 cm width excision and that would put him at risk for problems in his donor area, possibly not being able to close the wound. These two medical groups made promises that were completely unrealistic. Of course I can not tell what they would have done had he come into their offices for the surgery. Would they have sold him 5,000 grafts and split the grafts into one hair units? Even that, with a 1.3 density, would doubtfully yield that number of grafts. Would they have charged him for 5,000 grafts and delivered only 2,000 (or less) single hair grafts?

What is irking me is that the promises over the phone were either misrepresenting what can be done, or it was part of a market scam. I stick to my pitch: Let the Buyer Beware!

Hello Doctor,
Maybe a slightly unique question here… I have about an inch forehead scar in the hairline(above right temple side of head) I received from injury back in April, and had it revised with a scar revision procedure in June. Results are good (about 2 months into the healing/remodeling phase), but I’m facing facts here: I want the hair back where the incision-line scar is, no matter how less/ or barely visible the scar is overall…

My question would be at the 3 month mark here in September (if 3 months matters, as that is when I have my follow-up with the plastic surgeon who performed the revision at that time as well), would I be able go forward with the minor transplant without jeopardizing the healing scar? It’s primary (main) healing phase is already complete, right? So, would I be safe in getting the procedure done? Or could I jeopardize the scar or general healing phase of the area at all? Thanks so much for your help; I read your blogs frequently.

I would have no hesitation to transplant the area after 3 months have passed, but might be concerned at less than that time period. The basic scar healing should be complete by then. For those curious about the various phases of wound healing, check out this article.

In the early days did you ever perform a surgery like this? (hair plugs)

No, I never did the large grafts placed into holes (commonly called hair plugs). I started with my own practice in late 1992 and immediately went to large quantities of small grafts (at the time 1.5mm grafts into punch holes with each graft containing about 3-5 hairs each). I quickly reduced the size of the grafts to 1.25mm grafts, reducing the number of hairs per graft to about 2-4 hairs each and I used all of the single hair grafts in the front of the hairline.

At that time, the follicular unit was not recognized as the “golden standard” that is, until we published the classic article on follicular unit transplantation in the mid-90s (read it here). By 1994, we were using small grafts into slits and many of these grafts were follicular units. Our number of grafts had climbed to as high as 4000 grafts in a single session.

Hello Dr. Rassman,

With regard to future donor density/yield, what is the better option:

Several small strip procedures or one very large procedure?

What I’m basically asking is which one would be more detrimental to your donor supply for future transplants (possibly affecting laxity)?

I have to speak in generalities, something that I do not like to do as every situation is different. Generally speaking, the less the number of surgeries the better for the donor supply, but as larger and larger sessions are tackled, the surgical team is as critical as other items such as donor density and laxity. Each surgery has a built in waste factor (I estimate it in a good doctor’s hands at about 4-5% in a strip surgery) so two surgeries will produce more waste (a relatively small amount of waste). In the hands of a surgical team not designed for very large sessions (over 2000-2500 grafts), the larger session might cause a longer surgical time, more time for the grafts to be out of the body, and more time for dessication (drying of grafts causing graft death). Longer surgeries require more anesthesia and a skill in managing the anesthetic requirements is critical for larger sessions. In the rush to keep pace among the field’s leaders, many groups try to offer larger sessions (3000-5000 follicular unit graft range) even though they are ill prepared for this service. Some groups dishonestly sell these larger sessions and do not deliver on them, yet do charge for them… causing a fraudulent transaction (more common than most doctors will admit to, i.e. “It’s the other doctor, not me!”).

You were right to ask about the future donor supply. Very large sessions may reduce your donor supply very significantly when they are done, so it is good to understand what the session will do to the Master Plan for the patient. Running out of donor supply could be a critical error if it is done in one session. Look at today’s 12:31pm post (2 down from this post) and look at the real donor supply. Any hair taken outside this rim of hair is not permanent so if the doctor goes too high or too low, you may find out in the long term that what you received is not permanent.