Paired Graft vs. Intact Graft

From July 2009 Dr. Michael Beehner’s report ~

One intact 2- hair graft: contain two single hairs follicular unit. This can also be cut into two 1-hair follicular units (paired graft). *paired graft=combine two grafts and insert into one slit.

One intact 3-hair graft: contain one single hair follicular unit and one two-hair follicular unit. This can also be cut into one 1-hair and one 2-hair follicular unit (paired graft).

BFU=Bi-Follicular Unit

Conclusion from Dr. Michael Beehner:

Intact follicular unit’s growth rate is better than paired grafts (93% vs. 70%)
3-hair follicular unit has higher growth rate than 2-hair follicular units. (99% vs. 83% on intact 2-hair graft, 49% on paired graft 1 hair+1 hair

Comments:
Intact follicular units and 3-hair follicular units are our modified follicular units (bi-follicular unit). Paired grafts are single follicular units. This is why our modified follicular unit (bi-follicular unit) has higher growth rate.
Another reason why we opposed to the paired graft is that the goal of hair transplant is to minimize the empty spaces among the grafts. When transplant same size of donor area and hair, paired grafts will increase the empty space.

The photo below shows the scalp skin. If you paired the blue circled hair into adjacent hair, the empty area will increase almost four times.

From another point of view, the intention of hair transplant is to use lesser amount of hair to cover a bigger area. But when you pair grafts, it covers less area. That’s against the purpose of hair transplantation.

Look at the picture above and imaging that if you paired all the hairs, the empty space becomes huge and unnatural. If you want to keep same space then we have to remove 50% of empty skin. Transplant area will be reducing to 50% smaller area.

Super dense packing (92 grafts/cm2), does it benefit the patients?

Here is the abstract of another presentation that I did at the 2009 ISHRS annual meeting.

Super dense packing (92 grafts/cm2), does it benefit the patients?

I. Introduction
For past several years, mega-session with dense packing is the main trend in hair transplant surgery. The graft number and density get more and higher every year.
Does it really benefit the patient in general?

II. Technique
To precisely calculate the growth rate of the transplanted hair, we transplanted hair onto eyebrow instead of the scalp. We transplanted 544 grafts in an area of 6 cm2. The density is 92 grafts/ cm2.

Prior to this case, we usually deliver a density of 40 to 50 grafts/ cm2 on eyebrow transplantation.

We compare the result of the growth rate to find out if super dense packing benefits the patients.

III. Discussion
Six months after the 92 grafts/ cm2 eyebrow transplant surgery, we counted 455 hairs. The growth rate is 82%.

We have done about 300 eyebrow cases for the past 15 years and the average growth rate is about 96%.

With the super dense packing technique, we have sacrificed 14% of hair.

To grow 455 grafts with 40 to 50 grafts/ cm2 density, we only need to implant 474 grafts. The last 70 grafts (544-474) were wasted.

In order to achieve 92 grafts/ cm2 density, we have to cut the graft much smaller and instead of making 19G coronal slit, we have to make 20G needle coronal slit.

When we transplant hair onto the scalp, we had the same result. http://hairtransplantion.blogspot.com/2009/08/chubby-vs-skinny-graft.html

In the process of preparing the smaller graft, the technician must trim off all the tissue next to the grafts. Bare graft obviously has lower growth rate.


IV. Conclusion
So far no one knows what the best density for best growth rate is, maybe we never will.

I’m sure that depends on age, health, nutrition, etc. everyone has different limitation. Without knowing the body’s limitation, only looking for higher density is not the patient’s best interest.

Chubby vs. Skinny Graft

The more denser-packing, the more skinny grafts.

Here are the study results that I can find about chubby vs. skinny grafts.






Conclusion:

All studies show that compared to the chubby grafts, the growth rate of the skinny graft is decreased 15% to 33%.

Virtually Painless Hair Transplant Anesthesia

I just attended the International Society of Hair Restoration Surgery (ISHRS) 17th Annual Meeting at Amsterdam last week.

Here is the abstract of my a pesentation about how to use anesthesia technique to perform a virtually painless hair transplant procedure.

Title: Virtually Painless HT Anesthesia

I Introduction
The ideal Anesthesia for HT includes many factors. Safety is a main priority. Blood pressure and heart rate must be monitored. Minimal blood loss, minimum airway obstruction and minimal if no discomfort for the patient is the ultimate goal for HT anesthesia.
This discussion will revolve around delivering painless anesthesia to the patient. There are so many nerves involved, so to apply painless HT Anesthesia is never an easy job.
The method I am going to mention I have being using for the past 15 years. We have modified it during the course of time and now all our patients appreciate it and have almost no side affects. I don’t recall the last time we have encountered airway obstruction, nausea or vomiting.

II, Technique- minimum sedation and stimuli
A. minimum IV sedation
The purpose of this is to relax the patients and not to put them to sleep.
Never give too much sedation. How to give the right dose is the most difficult part. Some practitioners might be reluctant to use IV sedation. The method works with just partial knowledge of the technique that I use.

B. always pre-numb the skin
Use a 30 gauge needle with bacteriostatic sodium chloride. Never use xylocaine for pre numbing purpose. Its ph is too low and will sting.

C. Two step super orbital block
Too my knowledge, not too many practitioners use a super orbital block because it is too painful to apply. I have created a 2 step block to reduce the pain to a minimum.
I pre numb the landmark with a 30 gauge needle and bacteriostatic sodium chloride and then apply 1cc of xylocaine on each side. I only stick the needle up to the subcutaneous area. The second block occurs after I remove the donor site and close it. It usual takes me about 30 minutes. By that time, even if I stick the needle deeper to numb the nerves, the patient usually doesn’t feel any or very minimum pain.

D. Massage.
Always use the vibrator if possible to interfere with the pain transfer path.

E. Inject the medication very slowly.
The speed of injection makes a lot of difference.

III Discussion
For sedation I use midazolam and narcotics fentanyl.

To prevent N&V, I screen my patients with two questions. Have they experienced nausea after previous surgeries and if they experience any type of motion sickness. If one of the answers is positive then I don't use any narcotics it at all. My max dose of fentanyl is 2ml.

I.V. midazolam relaxes the patient fast and efficiently, it never causes N&V, minimum cardiac impact and causes some amnesia.

We don't want to put patients into deep sleep, because it might cause airway obstruction. To give the right dose is very important and difficult. Everyone needs a different dose, so we give it incrementally in 10-15 minutes. In my experience I have never had to use antidote (Romazicon). I don't remember the last time I had to hold the chin to open the air way.

Worry About the Post-Op Scab safter Hair Transplant Surgery?

See what camouflage product can help you immediately after the hair transplant surgery.

If you can use it efficiently then you do not need to worry about the post-op scabs.

An Email from a Stranger

Subject: About NHT Philosophy

I checked your website and I was amazed with your frankness and integrity. I have had 2 hair transplant with very good results. I DID NOT get the surgeries done at your place. I went with another doctor who was a friend's referral. The reason why I'm contacting you is because I saw your gallery and read your Philosophy and was pleased with the way you present yourselves. As a prior hair transplant patient I KNOW what to expect from the procedure. I want to encourage people who check your website to definitely get a consultation with you because you seem very honest and explain REASONABLE expectations and your pictures are not altered to improve the appearance of results. Your website contrasts with the competition as you present actual results that are not photoshopped. Keep up the good work!

J. C. G.

Thirteen Years after Hair Transplant Surgery

One of my patients who had hair transplant surgery done 13 years ago (1996) came in yesterday.

He had two sessions and the total density delivered is 50% donor site density.

He is not taking Propecia.

Please see the before/after surgery photos.