Rahal Doesn't Do High Density Packing Anymore ...

[IdealForehead]

I saw Dr. Rahal for a consultation. He said that he aims for 50-60 follicular units per cm2 these days and then if you need it, on a second procedure that can be increased by 5-10% further.

I asked if he ever used to do denser packing, and he said he used to do up to 80 units per cm2 but he stopped. He says such high density is "hit or miss" as the more units you need, the more incisions you must make, which can affect blood supply and scarring.

He said at higher densities he has had great successes but also some failures. So he limits it to a more conservative 50-60 now. I was reading in a thread yesterday someone said a Rahal patient had a case of necrosis, which is a risk of any surgery.

I'm guessing that might have been what "spooked" him off high density packing.

Anyone have any perspective on what a typical natural density would be, if we were to (theoretically) replicate it with FUE? I'm guessing 100-120 or so would be a natural density, or is that too high?

Just interested for context. Also interested in any perspective on FUE densities and what other surgeons might have told you.

 

[SeanFUE]

Is that right?

 

[SeanFUE]

Just make sure any procedure you have with anyone is done by the actual surgeon, slowly paced, and using the right tools, preferably all manual if FUE. You do not want to be a repair patient at all. Best of luck to you

 

[IdealForehead]

Just make sure any procedure you have with anyone is done by the actual surgeon, slowly paced, and using the right tools, preferably all manual if FUE. You do not want to be a repair patient at all. Best of luck to you

Sure, but we are all talking about guys that are considered "generally good surgeons". Rahal is quite famous for being one of the best.

Erdogan is also quite famous for being among the best.

Both built their names at least in part by doing dense packing. Both have had amazing results. Both have had a few bad outcomes as a result. I have read one guy on here had complete loss of almost all his transplants with Erdogan. Without knowing the case, I can't say if it was from dense packing or not. But either way, the point is bad things can happen even with good surgeons.

Rahal has now said he doesn't do >50/60 units/cm2 anymore because of safety reasons. This is the conventional amount which I understand hair transplant surgeons have always generally said is a "safe" amount.

I think the point is if you're requesting a surgeon to go above this, you are taking a risk that there will be vascular or tissue compromise and you will suffer complications (graft loss or at worst skin necrosis) from this. I don't actually know the percent risk. Maybe it's only 1%. Or less.

But it's enough that Rahal has apparently decided it is not a good idea anymore. We didn't have a long discussion on this subject.

Our exchange was just a few sentences. I will try to paraphrase it as best I can from memory.

I asked what density he could provide and whether it would match my regular hair density. He said transplants will never match my regular hair, and that is not possible. He said he would aim for 50-60 units/cm2 (even though I have loads of donor hair and a small area we were planning for). I asked if he ever does higher density than that. He said he used to do up to 80 units/cm2, but for every unit you must make an incision, and when you are packing so many units into such a small area, that means a lot of incisions in a small area. There is then a lot of tissue trauma which increases risk of damage and complications, because there is less room for each unit to sit in. He said there have been many great outcomes with this density, but also a few complications, so he now sticks to 50-60 units/cm2. He said if it is necessary, a second procedure can be done to increase density 5-10% further. I asked if a second procedure could be done to increase the density to the equivalent of 80/cm2 or so, and he said no, he would not do that.

So clearly, it seems he has had a change of heart on the risks/benefits of dense packing.

I consider this more a commentary on the risks/benefits of dense packing in general than his surgical skill. I expect based on his results and reputation, and that he is still in his surgical prime, he is one of the absolute best in the world. So it is not about his skill.

It is about the fact that for an ethical surgeon, probably even a 1% chance of massive graft failure or tissue necrosis is simply too great. How could you live with yourself if you were a surgeon and had even a few outcomes like that? If you were ethical, it would make you reconsider your approach and try to make it safer so that won't happen again.

That doesn't mean we can't still pursue dense packing procedures from surgeons who offer them. I think it means clearly though we should really think hard individually about what the risks of dense packing are, and whether they are going to be worth it.

Any further thoughts or feedback from other surgeons any of you have chatted with appreciated. I think it's an important discussion to have.

 

[shookwun]

hes right. good ethical doctor.

which is why i repeatedly tell people, always always need another transplant to go over the same area for the desired out come



back in 2013 he 'dense packed' me, but i dont believe it was anymore then 50 units

 

[JeanLucBB]

Everything I have seen suggests that no more than 50 units per square cm in the hairline and 30-35 behind is necessary or most effective in terms of yield. The best results you see are typically those who opt for this and then a second procedure to add another 15-20% density beyond this which also stops a compromised yield and donor.

80 units per square cm is typical natural Caucasian density, but at that point you'll never be able to cover the entire head of even a NW5 pattern. Anything above 55 is diminishing returns and too high of a risk.

Obviously donor quality and thickness important too, Arabs, Asians, Spanish etc can often get perfection with a single procedure at 50 units per square cm but Asians have less density in their donor. Often 35-50% thicker individual hairs than average, and close 100% in extreme cases compared to bottom end Caucasian donors.

 

[IdealForehead]

I have been reading more about this subject and I think I have come to learn more about the situation.

Here are a couple good links on the subject:

http://www.hairestorationetwork.com/eve/163275-how-many-fus-per-square-cm-wise.html
https://www.hairtransplantnetwork.com/news/article.asp?CopyID=841

Key points:

• "The average hair density is often considered 80 FU/cm2."
  
• "I think no more than 50 per cm2 is wise. A little higher in some places, but you should probably do that on an additional surgery.

• "About 4-5 years ago, the various hairloss forums were buzzing with many posters expressing their goals by cm2. So and so got 70 FU cm2 and so and so got 80 cm2 from Dr. X and Dr. Y. And many were wanting the very same level of density without ever considering their individual hair characteristics. "Dense packing" became the prevalent buzz words! Yet in the end, dense packing was counter productive to actual yields (regrowth) and the era died!"

• "I would rather place 60 FU's in a sq cm and get 56 FU's to grow rather than placing 80 FU's per sq cm and only have 68 FU's grow. Less wasted follicles is better in the long run. Everyone has a limited supply."

 

[IdealForehead]

Some more information here:
https://www.realself.com/question/india-normal-hair-density-dense-packing

• All in all normal hair density is somewhere between 170-220 hairs per sq cm ( ... or roughly 80 follicular units to 120 follicular units per sq cm). The back is more dense than the temples. The highest density occurs at birth and then slow reduces as the individual gets older.
  
  
• Dense packing refers to the placement of more than 35 follicular units per sq cm during the course of a hair transplant. Dense packing of 45-50 follicular units may lead to poor growth and poor surgical outcomes in some patients.

So in all fairness to discuss "dense packing" we'd first have to come up with a consistent definition for what that means. Personally I think 50 units per cm2 is the "standard" nowadays so anything above 50-60 should be considered "dense packing".

Anyway, point is if you have naturally dense hair, you may be up to the equivalent of 80-120 units/cm2 naturally, and even a "dense packed" job of 60 units/cm2 is not going to come close to matching it.

You'd have to get a job done at 70-80 units/cm2 to do this, and then you'll have a much higher graft failure rate and risk of catastrophic outcomes.

Overall, getting a truly dense transplant, even with minimal balding and loads of donor hair does not seem technologically possible.

 

[Nick1990]

what would 30 of grafts per cm2 be like... or possibly even less.. say 20/25

 

[JeanLucBB]

what would 30 of grafts per cm2 be like... or possibly even less.. say 20/25

30 per cm2 is standard across midscalp and crown. Roughly 7000 FU in average donor area after both FUE and FUT, then 180cm2 typical for entire balding area. That = 26ish per square cm in the case you go full cue ball.

People need to understand though that you don't NEED these massive graft per square cm numbers that some espout, and a lot of doctors claim higher numbers than they're doing to make people think they have an edge. 50 square cm in a hairline will do well and 25-30 elsewhere will look fine grown out reasonably wrong with a decent hair caliber.

 

[Nick1990]

its like this dude 3700 grafts in the front that is just a ridiculous amount...

im quoted for 3900 all over my bald *** head!

 

[john12341]

look at him at 6.5 months

it seems like they made the front too dense, so now the hair behind it looks bad

 

[Nick1990]

look at him at 6.5 months

it seems like they made the front too dense, so now the hair behind it looks bad

yeah exactly I personally see that as a waste and for the amount of grafts it doesnt look particularly dense tbh...

 

[SeanFUE]

If you have decent native hairs and a Doctor puts high density or low density into that zone, your whole procedure could fail. You do not want to become repair patients obviously. There are many factors to this though. Even surgery ethics, who is doing extractions, surgical aspects of surgery etc. be weary of rotating or student technicians and etc. Be weary of number of surgeries being done at the same time as yours.

Make sure the doctor you go with promises to give your entire f*****g surgical health record after surgery and not omit or remove anything. That is also true for every page of surgical consent forms you signed.

The last thing I would want is for anyone to go with such a procedure with any Doctor and become a repair patient. It is not as straightforward as some of you may think. You can try doing a small patch test first, but honestly, no doctor should act confident and say they can get high yield and etc etc etc.

If anything, before you actually book a surgery with any Doctor or put down a deposit, ask the Doctor or their rep to send you the entire surgical consent form you have to sign right before surgery. Most docs do give it out FYI via email prior to surgery. Only then, you will realize what a Doctor is trying to protect themselves against. It does not matter how good or bad any Doctor is.

High density is very risky and apparently can screw you up so bad that a future repair might hampered. Once you get ridging and etc then you will face even more difficulty.

As a war Veteran, I am trying to get my life on track, hair restoration was a way for me to move forward. But with what I am going through, with surgeries to repair, it is taking a toll and is very damaging. Sometimes folks wish they can turn back time and not listen to the hype. Best of luck to all that give this procedure a shot. Definitely, play your cards right and take it very slow.

 

[IdealForehead]

If you have decent native hairs and a Doctor puts high density or low density into that zone, your whole procedure could fail. You do not want to become repair patients obviously. There are many factors to this though. Even surgery ethics, who is doing extractions, surgical aspects of surgery etc. be weary of rotating or student technicians and etc. Be weary of number of surgeries being done at the same time as yours.

Make sure the doctor you go with promises to give your entire f*****g surgical health record after surgery and not omit or remove anything. That is also true for every page of surgical consent forms you signed.

The last thing I would want is for anyone to go with such a procedure with any Doctor and become a repair patient. It is not as straightforward as some of you may think. You can try doing a small patch test first, but honestly, no doctor should act confident and say they can get high yield and etc etc etc.

If anything, before you actually book a surgery with any Doctor or put down a deposit, ask the Doctor or their rep to send you the entire surgical consent form you have to sign right before surgery. Most docs do give it out FYI via email prior to surgery. Only then, you will realize what a Doctor is trying to protect themselves against. It does not matter how good or bad any Doctor is.

High density is very risky and apparently can screw you up so bad that a future repair might hampered. Once you get ridging and etc then you will face even more difficulty.

As a war Veteran, I am trying to get my life on track, hair restoration was a way for me to move forward. But with what I am going through, with surgeries to repair, it is taking a toll and is very damaging. Sometimes folks wish they can turn back time and not listen to the hype. Best of luck to all that give this procedure a shot. Definitely, play your cards right and take it very slow.

Thanks for your reply. In your first paragraph, are you saying doing a transplant into decent density areas (ie. If you're trying to thicen up your corners) increases risk of graft failure? Do you mean damage to the native hairs as well?

If you don't mind can you share what happened in your case? If you have posted it somewhere else a link would be appreciated.

What density range would you consider high density for transplants when you are talking risks like this?

 

[SeanFUE]

Thanks for your reply. In your first paragraph, are you saying doing a transplant into decent density areas (ie. If you're trying to thicen up your corners) increases risk of graft failure? Do you mean damage to the native hairs as well?

If you don't mind can you share what happened in your case? If you have posted it somewhere else a link would be appreciated.

What density range would you consider high density for transplants when you are talking risks like this?

Absolutely, but this is my non doctoral and unprofessional opinion. If you have native hair in that area, not only can a Doctor negatively impact that area up and make it see through, it may hamper your chances towards a successful result apparently. If you do decide to go with 50cm2, it is probably wiser to wait until the area you want hairs with that density is slick bald and is not loaded with native hairs. Not only can you risk transection, your weaker native hairs could suffer permanent shockloss so you end up with less density as a result. You will be surprised on how many folks I know have hairline issues as a result of this situation etc etc. Their native hairs were far more thicker then the transplanted recipient hairs and densities discussed were not on target. Imo in general, that whole density stuff is unethical marketing as it does not apply to all persons (per some folks, it can equate to marketing fraud). Because Density is also dependent on the texture of your hair to the caliber in microns. If you have thicker hair, it might survive FUE extractions better and the bulb is bigger so it maybe is easier to extract via fue extraction. With straighter medium hair, your hair could be a bigger challenge to extract and i personally now think Manual fue extraction via nice and slow is the way to maximize yield for this hair type for FUE. Also, ethnicity is important and rarely discussed, as for some ethnicities, FUE is riskier vs others. Clearly FUT may suit one patient more than FUE or vice versa. The rules aren’t same for all. Depending on hair shaft thickness, 45cm2 for some may suffice, while for others it may not. I think no professional should eye f*** your hair and tell you this is how much donor you have or this is how much density you can get without using proper tools that can tell you how much donor grafts you have or what micron is your hair obviously.

For any doctor, You should definitely review actual surgical consent forms in detail and talk to as many patients you can prior to any deposit paid. Like I said, there are docs that supply them upfront vs the day before or on the day of your procedure. See actual patients in person for the same type of hair loss with similar hair textures and number of grafts. Get multiple opinions and weigh the options you feel comfy with.

Honestly, wish you the best in your journey. If you decide to share your progress, it may help folks learn.

*Any surgeons for any surgeries I may have had, have absolutely no permission to talk to any prospective patient/any persons about me or my surgeries obviously. If that is the case, I’d like to be informed. I have given no such authorizations + it’s against HIPAA.

 

[IdealForehead]

Absolutely, but this is my non doctoral and unprofessional opinion. If you have native hair in that area, not only can a Doctor negatively impact that area up and make it see through, it may hamper your chances towards a successful result apparently. If you do decide to go with 50cm2, it is probably wiser to wait until the area you want hairs with that density is slick bald and is not loaded with native hairs. Not only can you risk transection, your weaker native hairs could suffer permanent shockloss so you end up with less density as a result. You will be surprised on how many folks I know have hairline issues as a result of this situation etc etc. Their native hairs were far more thicker then the transplanted recipient hairs and densities discussed were not on target. Imo in general, that whole density stuff is unethical marketing as it does not apply to all persons (per some folks, it can equate to marketing fraud). Because Density is also dependent on the texture of your hair to the caliber in microns. If you have thicker hair, it might survive FUE extractions better and the bulb is bigger so it maybe is easier to extract via fue extraction. With straighter medium hair, your hair could be a bigger challenge to extract and i personally now think Manual fue extraction via nice and slow is the way to maximize yield for this hair type for FUE. Also, ethnicity is important and rarely discussed, as for some ethnicities, FUE is riskier vs others. Clearly FUT may suit one patient more than FUE or vice versa. The rules aren’t same for all. Depending on hair shaft thickness, 45cm2 for some may suffice, while for others it may not. I think no professional should eye f*** your hair and tell you this is how much donor you have or this is how much density you can get without using proper tools that can tell you how much donor grafts you have or what micron is your hair obviously.

For any doctor, You should definitely review actual surgical consent forms in detail and talk to as many patients you can prior to any deposit paid. Like I said, there are docs that supply them upfront vs the day before or on the day of your procedure. See actual patients in person for the same type of hair loss with similar hair textures and number of grafts. Get multiple opinions and weigh the options you feel comfy with.

Honestly, wish you the best in your journey. If you decide to share your progress, it may help folks learn.

*Any surgeons for any surgeries I may have had, have absolutely no permission to talk to any prospective patient/any persons about me or my surgeries obviously. If that is the case, I’d like to be informed. I have given no such authorizations + it’s against HIPAA.

Hey Sean, thanks for your detailed thoughts.

The "transplanting into areas of low density" issue has been a concern of mine.

The reassuring thing I have seen is I have seen several female cases like this:

Where a general "density boosting" transplant is actually quite successful. Probably they are keeping the "end goal" as <50 units/cm2 (total native and transplant combined density). So this is likely not too much different than transplanting 50 units/cm2 fresh into a truly bald scalp. At least it is likely no more dense in the end.

My case is unique. I am getting a forehead reduction due to being born with a very high hairline (3-3.5 cm too high), which will likely leave me with a mild linear scar along the hairline. I am planning to get a 3-5 mm of transplants in advance of that scar to cover it. If the density is too low, it will not match my natural density and will create a weird "border" at the start of my hairline.

Not sure if you have any thoughts on that possible issue. Anyway hope your hair has turned out okay in the end. Thanks again.

 

[SeanFUE]

Hey Sean, thanks for your detailed thoughts.

The "transplanting into areas of low density" issue has been a concern of mine.

The reassuring thing I have seen is I have seen several female cases like this:

View attachment 68138

Where a general "density boosting" transplant is actually quite successful. Probably they are keeping the "end goal" as <50 units/cm2 (total native and transplant combined density). So this is likely not too much different than transplanting 50 units/cm2 fresh into a truly bald scalp. At least it is likely no more dense in the end.

My case is unique. I am getting a forehead reduction due to being born with a very high hairline (3-3.5 cm too high), which will likely leave me with a mild linear scar along the hairline. I am planning to get a 3-5 mm of transplants in advance of that scar to cover it. If the density is too low, it will not match my natural density and will create a weird "border" at the start of my hairline.

Not sure if you have any thoughts on that possible issue. Anyway hope your hair has turned out okay in the end. Thanks again.

Interesting, my forhead issue along with thinning was a reason for procedure. I even contemplated forhead reduction but didn’t go through with it. For this procedure, Proper facial framing is also key for this situation. Make sure you make a design on where you want hairline to be and email it to the doctor(s) you consult with. On the day of surgery, you should receive no pushback after you paid your damn deposit+fees that the doctor has something else in mind or would disagree to your initial design concerns. Make sure of that. Proper facial framing is also an important aspect to this procedure as forhead is a concern for you too. It should definitely be done properly in and around the scar carefully as vascularization may be compromised.

Oh trust me, you definitely do not want any border on the hairline, especially a see through one. I completely understand.

 

[SeanFUE]

Thanks Sean. My surgeon (Dr. Fleming) is incredibly nice and flexible and I have done extensive mockups about what my target is. I don't think we'll have trouble there. The main problem is I can't anticipate the scarring.

Dr. Fleming has said the scarring should be minimal as he uses a trichophytic closure. He has also strongly counselled me against getting any significant degree of transplants in front of his forehead reduction, as he says the same thing as you - the density will not match my own, they will be "see through", and I will end up with a small border of very weak hair in front of my strong native hair. (I still have very good density and have halted my hair loss so the native hair is very strong.)

Sounds like you would advise the same huh? If so, I may avoid transplants altogether and just try to treat any scar that results with lasers and other treatments.

If that's also the case, I should very much aim for my "final result" on this procedure, and not aim a bit higher to make "room" for the transplants...

Would you agree with all that as well?

Thanks again for any feedback. Getting your thoughts is very helpful.

Yes, you make very valid points and concerns. Imo, See how the scar heals first and let it heal for at least a year before you plan on doing anything if you decide to proceed with putting any grafts in and around the scar. Definitely share your feedback and experience. I an curious to see how the area heals and if lasers do help minimize scarring. At the same time, i would definitely try to see actual ptienta that have had this procedure done. This way, you know what is to come. Ask these patients healing times or any discomforts they may have faced, including numbness and etc. if you decide to get any transplant, it is probably wose to get a very minor test session to see what type of growth is expected. Usually, it is a small patch to see if you had significant growth or any issues. Hair restoration is definitely no joke and may give more complications. Best of luck. Wish you the best.

 

[SeanFUE]

IdealForhead, did you get most questions answered from dr Fleming? Hope your concerns were addressed.