Determining the Number of Grafts for the Hair Restoration

Attendee: Can you tell me how many grafts you would think that I would need?

Dr. Bernstein: [Examines patient] For this very early Norwood class 6 patient, I would suggest about 2,300 grafts. So the question is why this number? Why not fifteen hundred, why not three thousand? The reason is that the patient doesn't have tons of donor supply for the hair transplantation procedure. He has a number of limiting factors. The density of his hair is low, it’s 1.9. The average person’s density is 2.2-2.3. So that limits the amount of hair we have available to us. He has fine hair, medium fine hair. The average person has hair that has a little bit more weight. And then he has less scalp mobility than the average person. His scalp is slightly tight.

Everything here seems to be negative for a hair transplant surgery. Does he have anything that’s good at all? Well, actually he does. There are some things. One thing is that he has hair loss in the front. If we just put hair in the front and left his crown bald, he would still look a lot better. So even if we did modest hair transplantation, we could still improve his appearance.

So he has enough hair loss to warrant surgical hair restoration even though he doesn't have a lot of donor hair because his density is a little low, his scalp is a little tight, and his hair is a little fine. He's a good candidate because number one, he needs it; number two, his hair loss is in the right spot for a hair transplant, it's in the front. What else?

Attendee: Low Contrast?

Dr. Bernstein: Right. He has low color contrast. So a modest amount of hair is going to be filled in with the background color of his scalp, so it will look fuller. What else is good about his hair characteristics?

Attendee: His age?

Dr. Bernstein: Yes, he is older so his hair loss pattern is more predictable and his expectations are more reasonable. When I drew his hairline, he smiled – he was ok with it. He didn't say, "Uh, Oh, it’s that high up?"

So his expectations, his age, light skin, and hair color contrast all counterbalance the density and scalp laxity and fine hair – things we said were negative. Some of the things that we haven't spoken about are, first of all, whether the crown is very important to him. If I can convince him that just transplanting the hair in front and top will be adequate to improve his appearance and he buys into that, then we can go ahead. If he says, “what I had in mind is filling in the whole thing and if you can't do that, I'm not interested,” then he's not a good candidate for hair transplant surgery.

And then the final thing is Propecia. If he goes on Propecia and it enables him to hold onto what he has, or the finasteride slows down the hair loss, that will also give him some benefit.

Fifteen hundred grafts would not be enough to cover the front and top, three thousand would use too many grafts in the first session and risk a wider scar (since he has a tight scalp). Using too great a percent of a patients total donor reserves in the first hair restoration session, doesn’t allow us to have as much aesthetic flexibility in the second session. For example, say he only had 4,000 total follicular units to move. If after the first hair transplantation procedure, he felt the front was still too thin, we could use the second session to increase the density with another 1,300 grafts and still have 1000 left over for future balding. However, if the first session used 3,000 grafts and extended into the crown, as the crown expanded, it would require even more hair to look natural, so increasing the density in the front might not be possible.

Another advantage of leaving hair for a second hair transplant session, particularly in someone with limited donor supply is to be able to weight the second session. For example, patients with fine hair can increase the appearance of fullness by combing their hair to the side. This look can be enhanced by placing more hair on the part side in the second session. Before the first hair transplantation session, the patient often has no idea about future grooming, so these decisions are more difficult.


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