Bernstein Medical - Center for Hair Restoration - Desiccation

Desiccation

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Q: What causes graft popping during a hair transplant? G.K. – Carle Place, N.Y.

A: Popping, or the tendency for grafts to elevate after they have been placed into the recipient area, is caused by a number of factors including:

  • Packing the grafts too closely, particularly when they are placed on a very acute (sharp) angle with the skin
  • Rough placing techniques
  • Bleeding
  • Poor fit between the graft and recipient site
  • Natural characteristics of the patient’s skin, including the elasticity and stickiness of wound edges

The problem with popping is that it exposes grafts to drying (while they are elevated on the skin surface) and trauma (when they have to be re-inserted).

The judgment and experience of the surgeon performing hair transplants is extremely important in minimizing popping. It is important that the surgeon customize the site size to the different size follicular unit grafts and to test the recipient sites as they are made, to make sure that the “fit” is perfect.

Although it is important to place grafts close together to get the best cosmetic result possible, over-packing of the grafts risks popping and other factors (such as overwhelming the blood supply) that may lead to poor growth.

In the end, maximum growth of the transplanted hair should be the primary goal.

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Q: When a donor strip is taken out during a hair transplant and separated under the microscope, you can read on the internet that there is a wastage of grafts (about 15%), because of those unseen telogen hairs. What do you think about that and how does it affect the hair restoration? — T.B. Baldwin, New York

A: The Telogen phase of the hair cycle is about 3 months long and about 12% of follicles are in this phase at any one time. It is speculated that the follicles may be empty for perhaps 1/2 that time (this number may vary significantly between people). Therefore, approximately 6% of the hair follicles may be in telogen at any one time.

On average about 15% of the follicular units are 1-hair units (but this also may very greatly between patients). If 6% of all follicles are “empty” telogen follicles, then there should be .15 x .06 = .009 or about 1% of the patient’s 1-hair follicular units in the empty telogen phase that can’t be identified and will be missed on dissection.

The 1% isn’t very large. However, also consider that the remaining 5% of the empty follicles are associated with larger follicular units (i.e. those with 2-4 hairs). If these follicular unit grafts are closely trimmed, as is the practice with very dense packing, a much more significant number of follicles are at risk of being lost. With chubby follicular unit grafts (i.e., where the microscopic dissection leaves a protective sheath of tissue around the follicles) the risk should be closer to the 1%.

The lesson for hair transplantation is that over-trimming of grafts, for the sake of very dense packing, may waste telogen hairs as well as place the grafts at an unnecessary risk of mechanical trauma, drying and warming.

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Q: Does dense packing hurt grafts? — P.L., Rye, NY

A: There is no absolute answer to this question. In a hair transplant, dense packing of grafts has a risk of decreasing yield if there is a significant amount of photo damage to the scalp (which alters the blood supply) and if there is a tendency for the grafts to pop (this is difficult to predict pre-operatively). Very closely spaced grafts exacerbate the popping and expose the grafts to desiccation (drying), hypoxia (lack of oxygen) and mechanical trauma from the necessary re-insertion.

That said, the skill of the hair transplant surgeon and placing team, the size of the recipient sites, and the way the grafts are dissected and trimmed all play important roles in determining graft survival in dense packing.

Read a thorough analysis of the “pros” and “cons” of large hair transplant sessions
Read answers to more questions on dense packing of grafts

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