Here are few examples of patients in which I believe dense packing in the hairline area is appropriate. I consider planting at densities between 40- 60FU/sqcm as dense packing. There are patients in whom I will plant at densities from 60-80 FU/sqcm, but they are the rare exceptions and need to be perfect candidates for what I would call super dense packing.
In order for me to feel comfortable dense packing the hairline I think the following criteria need to be met:
1) The patient must be at least 30 years of age
2) The patent should have a family history that suggest his balding will not progress furhter then a Norwood type IV.
3) The donor area has to have at least an average density of 80/FU/sqcm
4) The donor area has to have good laxity
5) The hair behind the hairline should have no or little evidence of miniaturization.
6) The crown should have no or little evidence of hair loss or miniaturization.

At SMG we have a camera which can take close up photographs of a 1 sq.cm area of the skin which allows us to get a measurement of donor density and the density of our incisions. That is how we can get an accurate measurement of density. As you can see, to get an accurate count the existing hair has to buzzed. We rarely take postoperative density photographs because most post op patients do not want to buzz their new hair. Even it the patient did buzz his hair it is difficult to tell previous existing hair from transplanted hair in post operative photos. That is one of the reasons it is so difficult to do accurate post operative density studies. These cases were both done within the last month so I do not have 6 month results. I will post them when they return for their follow up visits.

Case #1 I packed at a density of 60-80 FU/sq cm. He had all the criteria for a case in which I feel comfortable packing at super high densities. He is a 33 year old male with no family history of hair loss more than a Norwood type IV. He has great donor density of greater then 100 FU/sqcm., and no miniaturization or hair loss behind his hair line. He also had no evidence of hair loss or miniaturization in his crown. I must stress we do not get many patients like this. But he is a good candidate for super dense packing. The photographs show my incisions ranged from 60 -80 FU/sq.cm. A total of 2164 FU’s were planted.
Below are photographs showing his donor density, the density of my incisions, and day of surgery photos: (in the photos where the title is Hairs/sq.cm., it should read FU's sq.cm)

DONOR DENSITY


INCISION DENSITY


DAY OF SURGERY PHOTO, (before and after comparison)


Case #2 I packed at densities of 40-50 FU/sqcm. He represents the more typical patient I see in which I feel comfortable doing dense packing. He is a 38 year old male with most of the males in his family not progressing to greater then a Norwood type IV, but he did have an uncle who had Norwood type V hair loss. His donor density was not as good as case #1 and there was some evidence of miniaturization in his central core and crown areas.

DONOR DENSITY


INCISION DENSITY



DAY OF SURGERY PHOTO, (before and after comparison)

This is a very informative thread, but when you describe the DONOR DENSITY with 106 and 80 hairs in the pictures you mean FU's, right?

Dr. Paul,

This informative article and photo demonstration will help prospective patients help to understand when dense packing is and isn't appropriate. I've taken the liberty of transforming this post into a blog on our highly popular Hair Loss Q&A Blog.

To see this article, view "Who are Optimal Candidates for Hair Transplant Dense Packing?.

Thanks again for helping to educate the members and guests of this community.

Best wishes,

Bill (Falc)

Very nice post; and that work looks truly beautiful!

Makes me feel happy that I could have some form of dense packing, my natural hair is thicker than this guys and I'm near 34 now.

Very informative and great pictures. I know it's dense-packing, but it's as if I can almost see all of the grafts in these photos. It makes me jealous, cause I'm pretty sure that I don't qualify for dense packing!

Additional to my first question (hairs vs. FU's) I would like to know how many percent of your patients did you treated with dense packing like this example? And is it possible to see more photos from SMG with dense packed hairlines!?!?!

Thank you in advance...

I'm a little confused by this. In the original post, Dr. Shapiro says dense packing would be in the 40-60 FU/CM2. I thought 40 FU/CM2 would be considered a normal density to do an HT? Is the normal HT usually done at 20-30 FU/CM2 or is it that only the hairline is not usually packed at this density?

quote:

Originally posted by AJKV:
Additional to my first question (hairs vs. FU's) I would like to know how many percent of your patients did you treated with dense packing like this example? And is it possible to see more photos from SMG with dense packed hairlines!?!?!

Thank you in advance...

Yes I did mean FU's not hairs. Sorry for the confusion. I need to change the titles of the slides. Where ever the slide said hairs I did mean to put FU's.
It is only within the last two years we have started to take detail photos of patient’s donors and recipient sites and we only started to do this consistently within the last year. One of the reasons I started to take these detailed photos is because we did not have very good documentation on what we were doing during our surgeries. And I wanted to know in more detail exactly what I was doing in a surgery.
I also was interested in documenting the average donor densities since that seemed to be a constant question.
So unfortunately I can't give you an accurate answer to your question. I would say that very few patients qualify for the extra dense packing. I would guess that 1%-5% of our patients qualify for extra dense packing.
We end up planting grafts at densities of 40 to 50 FU/sqcm in many of our patients, but I can’t give you a percentage. In some patients we only pack at these densities behind the hairline, especially in the central core area but in some patients we do pack this densely in the hairline. As I take more photographs during surgery I will be able to answer this question more accurately. Remember 20% of the male population will be a Norwood type V to VI by the time they are 60, and 10% will be a Norwood type VII. So in patients who are too young to tell how they may progress or in patients in which we have a lot of evidence they may progress to a Norwood type V or greater we tend to pack more in the 30 to 40 FU/sqcm densities. The densities we pack at also depend on the cosmetic goals of the individual patients. Some patients don’t care too much about their balding crowns and would rather look denser from the front, while others are very concerned about their crown loss. The difference in each patient’s goals will affect the density in which we make our incisions.
I hope this is helpful
Dr. Paul

I would of thought that 40-50 isnt dense packing, just average.

I've had 4 in person consultations and each said 40 FU/sqcm would do just fine for my hairline and temples. But they also said a second procedure touch up might be needed. I have course dark brown hair and a Florida tan.

One of the surgeons who told me this was Dr. Ron Shapiro on his vacation in Miami. I'll most likely go to him or his brother in the end since they are the kings of hairlines.

I agree, I've seen some spot results from these guys, and imagine they will always stand by thier work, so you know your money isnt wasted.

quote:

Originally posted by Paul Shapiro, MD:

quote:

Originally posted by AJKV:
Additional to my first question (hairs vs. FU's) I would like to know how many percent of your patients did you treated with dense packing like this example? And is it possible to see more photos from SMG with dense packed hairlines!?!?!

Thank you in advance...

So unfortunately I can't give you an accurate answer to your question. I would say that very few patients qualify for the extra dense packing. I would guess that 1%-5% of our patients qualify for extra dense packing.
We end up planting grafts at densities of 40 to 50 FU/sqcm in many of our patients, but I can’t give you a percentage.Dr. Paul

Dr. Armani and Dr. Rahal consistently dense pack the hairlines of their patients, both make their incisions with needles. Is it much more difficult for you to plant 70+ grafts/cm² than 40-50? And what do you think about needles to go over 60 or 70 grafts/cm²?

It would be very interesting for many people to see final results from SMG with dense packed (65+) hairlines...!?!?!

I'm sure it's theoretically possible to pack at any density you want. Even 100 FU/CM2. I think the idea is to preserve as much of the donor area as possible though for future work if needed.

I am glad I posted these patients because there has been some good questions about what is dense packing and why are some clinic reporting planting in the hairline at a density of 70FU/sqcm.

We should not lose sight of the basic principle of hair transplant surgery which is: We are using a limited donor supply to cover a potentially expanding area of balding scalp. I wrote a post called “How Many Grafts Are Needed for a Hair Transplant Surgery” in which I reviewed this principal. The post can be found on the following link: http://hair-restoration-info.c...66060861&m=615103223

Another useful tool is the graft calculator in the HTN’s multimedia center. If you go to the following link: http://www.hairtransplantnetwork.com/MM-center.asp it will bring you to the multimedia center. Scroll down the page to the box that is titled “calculate # of grafts needed”. As you can see, if you want to plant hair at a density of 45 FU/sqcm. in the front ½ of the scalp (areas 1,2,3 &4) we would need to use 4,300 grafts. Studies suggest that the average lifetime donor for most patients is 4,000 to 8,000 grafts, with the average being 6,000 grafts. We need to take into consideration future hair loss when we plan a hair transplant surgery. That is why I only dense pack in patients who are at least 30 years of age, and I can confidently predict they won’t advance to a Norwood type V or greater.

Even though we can technically plant at densities greater then 40-50FU/sqcm, as I have shown in this post, I believe it is usually not the appropriate thing to do. I would say on average we plant at densities between 30 to 40 FU/sq.cm. We can plant at higher densities but the majority of our patients do not qualify for dense packing. At SMG we cut our blades and they usually measure from .6mm to 1mm. With proper magnification it is not difficult to make incisions at high densities from 50 to 70 FU/sq.cm. So in answer to one of the questions I do not believe there is a difference in whether we use cut to size blades or small needles.

Another point I would like to make is that we are using 1,2,3, and 4 hair FU’s in our transplants. It is important to mention hair count as well as graft count to accurately describe our surgeries. Planting 2 hair FU’s at a density of 30 FU’s’sqcm give us more total hairs then planting all one hair FU’s at a density of 50 FU/sqcm. In the first case we end up with 60 hairs and in the second case we end up with 50 hairs. We have 10 more hairs at the lower density of 30FU/sq.cm. What most of us do in hair transplant surgery is to distribute the 1,2,3 and 4 hair FU’s at different densities to give us the best results possible.

Taking into account the principle of limited donor and selective distribution of different size hair follicles I would say that in on average we plant at densities between 30 and 40 FU/sqcm. We may plant the one hair FU’s at a higher density and the four hair FU’s at lower densities. That is why it is difficult to say exactly at what “density” we are planting in a hair transplant surgery. The density varies depending on the size and caliber of the FU . In fact, I do think it is more common to plant one hair FU’s at densities of 40-50 FU/sqcm. Thus, I would call dense packing any case in which we plant the 2 hair FU’s at densities greater then 40FU/sqcm.

I hope this is helpful

Dr. Paul Shapiro