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Dr Rassman,

I’m a Caucasian 27-year-old male with zero known family history of MPB. However, I’ve lost some hair on the front of my head, and crown miniaturization was detected — meaning that down the road, I could have a serious (Norwood 6?) pattern. I started taking Propecia and hope it can hold onto my hair for 5+ years.

That said, I already need a transplant. (A “conservative” well-regarded doctor recommended 1400 FUT.) I understand the need for a Master Plan and to not run out of donor hair too early. However, it’s very important to me to not be viewed as balding as a young man (I’m single and haven’t firmly established a career.)

I have fair skin and dark brown hair. Luckily, I’m blessed with wavy hair, donor density 2.3, that people commonly describe as coarse and thick. So, I’m wondering, how big of a transplant could I do now for the front of my head, and still leave enough donor hair for future loss? Could I transplant 2000-2500 grafts without worry? I imagine other patients might be in a similar situation to me.

Thanks so much.

Everyone is different. A 2.3 density suggests you have more hair in the donor area than many people, and with coarse hair you may be able to cover an extensive pattern. But for those with fine hair, it may not be enough to cover a class 6 or 7 balding pattern. I have many patients who have had more that 6500 grafts and most of them get quite depleted. A few of these patients have gone to 10,000+ grafts like this man, and although he could have passed the 10,000 graft number, he got realistically what he needed.

If an unlimited supply of donor hair were available, could transplant surgeons give a patient the 200 hairs per cm squared that the average human head has or would a new tool smaller than the .5mm tool im aware need to be created to achieve this look?

I suppose you can achieve 200+ hairs per cm squared (which is about the average for a non balding Caucasian male), but I find most people who are obsessive with hair per square centimeter don’t understand the full story and are mislead by all the discussion groups on the Internet.

You can have 100 hair per cm squared and still look like someone with 200 hairs per cm squared, as this is not a numbers game. Furthermore, hair transplant is NOT about the numbers and density. It is about the art of creating a natural looking hairline with minimal number of hairs you harvest.

With respect to graft survival, there may be some issues of the grafts surviving such close packing in ONE surgery. Now 200 hairs in a square centimeter is possible with multiple surgeries to the same area… but again, numbers do not translate to how it looks overall.

Hello dr rassman,
I did 1000 grafts FUE hair transplant one year ago, which was my biggest mistake in my life from 1000 grafts half of them didnt grow back , my donor area damaged considerably, my density in donor area was 85 grafts in 1cmm before surgery now its gone to 55 grafts in 1cmm , i calculated approximate 2500 grafts been damaged. dont you think FUE is a basic method and must be banned?

I’m sure the donor impact of follicular unit extraction (FUE) is rarely a subject discussed by many of the doctors doing this procedure. When the donor area has a below average density, the impact on the donor area is very significant and it may appear to look like Swiss cheese. When the density is high, this is not a problem.

Some doctors and patients seem to think that FUE is the answer to the ideal method of harvesting, but your example shows that it is not. Of course, it is possible that in getting out 1000 grafts, 2000 punch holes were made, but as I was not there, this is only speculation about a doctor that has perhaps not mastered the process. Damage to the donor area does occur with FUE, the question is just how much damage occurs in the hands of a skilled FUE surgeon.

I was reading this ‘Understanding Density’ article [PDF file] and it states that thinner ’see-through’ hair has a density of about 20 cm2. It also says that areas with a pre-op density of 20-25 FU/cm2 could achieve a post-op density of 40-50 FU/cm2.

Then, in the ‘Determining Number of Follicular Units’ article [PDF file] on the same web page, it says that: with a pre-op density of 20 FU/cm2 and a transplant of 20-25 FU/cm2, a post-op density of 40-50 FU/cm2(20-25 FU/cm2 x 100 cm2 area) could be achieved with a total of 2000-2500 grafts.

I’ve had 2 transplants to the frontal half area as shown in the picture in the article, but I still have a ’see-through’ appearance to some degree. My doctor has confirmed the 20-25 cm2 density was the goal, although it was never made clear to me that was his intention. Anyway, I’m assuming I have about the 20-25 cm2 density and I’d like to have another procedure to increase the density to 40-50 cm2. So, based on all this I’m estimating that I should get 2000-2500 grafts in my next procedure.

My question is: Do you agree with the info presented in these articles and do you think this is an accurate way to calculate how many grafts are needed? Also, are there methods/tools a doctor should be using to check scalp laxity and density to help with determining what can be harvested for another procedure?

Thanks

A hair density of 30-50% can produce a good look depending upon the coarseness of your hair and the color contrast of your skin and hair color. I have never believed that a hair transplant should bring you to 70% of your original density. The difference between people, based upon color/contrast and the coarseness of the hair, can be dramatic. A return of 50% of the original density in a person with fine hair will have a more see-through look than a return of 25% of the original density if the hair is coarse. So you see how difficult it is for me to understand your situation as the blanks (color/contrast and coarseness) are not filled in for me to include in the assessment.

The calculations are easy. The original density in a person with “average” hair density is hair is 2.1 hairs per mm square. That amounts to 1250 hairs per square inch (or 650 follicular units per square inch). You need to know the area we are talking about to do the calculations correctly, yet that is not really the answer as the variables which are not included will dictate the presence of a see-through appearance.

Hi Dr. Rassman,

Excellent blog. I read it every day and would love to add my question to the plethora of information available.

I have a question about donor supply. I of course understand that when it comes to strip harvesting, you can only cut out so much of the skin, and that only some of the hair at the back, below a certain line, is permanent. But I’d like to know why after using up all the available donor hair with reference to what you can get with the strip-cup method, you can’t go in and take more grafts via the FUE method. There is still plenty more permanent hair at the back and although it might be too low to cut into because of the nerves and muscles, using tiny punches to get it out I’m guess wouldn’t have negative affects.

Thinning out the sides too would I think also have the advantage of not only providing more donor hair, but it would also make the transplanted area not look as thin in comparison since you’re making this “thick” permanent zone thinner.

With doctors performing FUE where ever there is hair, even body hair, I’d like to know why you can’t just go after more permanent hair that you still have in the back of your head and on the sides.

Thanks!

Doing a strip harvest for the first hair transplant surgery and a follicular unit extraction (FUE) at a later time is generally not advisable, as you limit the donor density with the FUE. Essentially, you’re asking why doctors don’t try to thin the donor area as much as possible, but for many people having the sides and back of the head looking sparse would also be a problem. Then again, everyone is different and I would rather not make a rule without knowing your situation. If you start with strip harvesting, you should finish with strip harvesting if you go for another procedure.

One aspect puzzles me. In FUT a strip is removed and closed so a part of the scalp vanishes and is replaced by a thin scar. The areas adjoining the scar retain their hair density and very often with trichophytic closure hair grows out of the scar, again with no reduction in density.

In FUE follicular units are harvested individually. No large scar is generated but hundreds (thousands?) of tiny ones. However (and this is my main point), donor area density is reduced because the scalp from where the hair is removed does not vanish and is essentially now a tiny bald spot.

Does this mean FUE thins out the donor area in return for not creating a long FUT scar? Is that the trade-off?

Thanks for asking, as this can be a bit abstract.

When you remove a strip of hair (say 1/2 inch wide by 4 inches long) you are effectively removing skin and pulling the scalp from top and bottom. This in effect stretches the scalp/skin along with the hairs. So if you have a very, very precise measuring tool of hair density before and after the surgery, then you will definitely see a decrease in hair density after the surgery… but this reduction in density is very low and not perceptible to the naked eye.

When follicular unit extraction (FUE) is performed, many hundreds and thousands of hairs are taken out (and never grow back on that spot) so it is easy to see how this would also reduce the donor density.

Greetings,
Solid good data base you have built on this blog Dr. rassman. Thank you

My question is: Can you transplant hair from the upper sides of the head “left and right” about 3 inches above the ears, or is it only possible as a donor area to be from the lower back above the nick ? Reason I’m asking this question is because I have what i want to define as “Global hair loss/damage”. Meaning even in the donor area it’s clearly visible that i do not have a normal hair distribution/density “there is holes among the donor area” but, in my sides “just below the flat crown of my head” the hair is extremely healthy/dense/thick and can grow for long time with out being damaged.

Your time and answers are greatly appreciated

First I though you were describing diffuse unpatterned alopecia (DUPA), but if there are clearly areas of your scalp that are full and lush, and they are about 3 inches above the ear, I would rule out DUPA on first glance. I would have to examine you to understand what you are telling me.

As a rule, however, the donor fringe is only 2 1/2 inches high on the back of your head and about 3 inches high on the side above the ear. Donor hair implies that the hair is permanent when full balding (up to a Class 7) occurs. Note the diagram at right of a Class 7 figure and you will see the 3 inches high fringe above the ear. Donor hair taken above the 3 inch level will not be permanent hair for the advanced balding patient.

First off, great site doc. Very helpful.

My question is about hair density and thickness. Say one buzzes their hair, should they expect the density and thickness of the hair to be the same over the whole head or are the backs and sides of the head thicker than the top of the scalp, generally?

Thanks, doc!

If you’re not balding, the density should be the same all over the head. If you are balding, density will vary with the pattern of genetic balding. Of course, there will be normal variations as well.

How many more grafts can you gain if you add FUE. Say i had three strips for 6000 grafts and i’m stripped out. how many on average more grafts can a person get with FUE? One doctor said between 1000 and 2000. Does this sound accurate? thank you

Your laxity might be good after three strip surgeries, but some patients might find the donor area to be tight. The higher the density at the time of the follicular unit extraction (FUE) harvest, the greater the yield will be. For an FUE, the remaining density will reflect your depletion of 6000 grafts from the original permanent zone. For those men with a high original density, there could be many more grafts available… and for those with an average or below average density, the different yield could be significant. If I examined you, I might be able to give you an educated guess, but there is no general answer to your question. A graft estimate of between 1000-2000 grafts is possible, but an examination is critical to the estimating process.

Hello, I just had a wonderful procedure. Their offices were clean, procedures were excellent, and the staff was very accommodating. In 2002 I had 800 grafts done by another group in San Francisco and then again I just did 3500 grafts. The follicles were transplanted throughout my scalp approximately 25 FU/CM2. I have a very nice NW2 hairline. Also, I had a very high number of 4-hair grafts. Over 400 of them! They excised a strip of 3500 grafts and got 3703!!!

Do most of your patients get about 25FU/cm2 and are happy with it? I think it will be ok but just need reassurance.

A normal person will have 1250 hairs or 600 two-hair follicular units. When converted to cm/square, that would extrapolate to 100 follicular units per square cm. If you received 25 follicular units in 1 cm, that would suggest that in one procedure, the doctor returned 25% of your normal density on the transplanted area. This is often not really the case, as some areas will have higher densities put in and other areas lower densities. For a person with average weight hair, olive skin, and brown hair, 50% densities overall should be more than enough to produce a full appearance. If you had a high number of four-hair grafts, then that might mean that your overall densities are higher than average. I generally target 25% density return on the first session, but at times I will go higher or lower depending upon other factors.