•How Many Grafts Will Make Me Happy?

•What Drs. Rassman and Bernstein recommend

•First Follicular Unit Transplantation Session

•Total Number of Follicular Units Suggested for a Complete Restoration

One of the most frequent questions asked by potential hair transplant patients is: "How many grafts will I need?" The answer should:

• Take realistic expectations into consideration
• Reflect the patient's degree of hair loss, donor supply, and hair characteristics
• Be consistent with a long-term Master Plan to address future hair loss
• Address the number of potential procedures and time commitment required
• Consider the short and total long-term cost for the patient

An individual's goals must be realistic. For example, if a person has significant balding (i.e., a Norwood Class 6 or 7 pattern) and fine hair, then he should not expect a full head of transplanted hair. If he does, dissatisfaction will be inevitable. With at least 65-75% of hair lost (the typical loss in Class 6 and 7 patients), a thin head of hair is a realistic and achievable goal. Although a thin head of hair can dramatically improve patient's appearance, if he were to attempt to achieve his original density, he would run out of donor hair before the process could be completed and an unnatural appearance would result.

Working within reasonable expectations, the total number of grafts required for any one patient will depend upon hair and skin color, donor density, scalp laxity the thickness of each hair shaft, the number of hairs in each graft, and the character of the hair itself. The physician must consider these factors and the expectations of the patient in order to calculate the amount of work required. Even when these considerations are combined with the expectations of the patient, the amount of work required to make a person satisfied is sometimes difficult to predict.

NaivetŽ of the physician, even in those who specialize in hair transplantation, seems to be more common than many care to admit. The failure of the physician to establish realistic expectations often leads to an unhappy patient. This can only be prevented by providing a clear explanation of the hair restoration process, and specifically defining the benefits that the patient may expect to achieve.

Hair Color and Skin Color Contrast
Hair color and its contrast to skin color is one of the most significant factors that dictate the amount of work required for hair restoration. The lower the contrast, the fewer grafts are required. Blonde hair against fair skin and dark hair against dark skin are two examples of hair combinations that produce excellent results with less work on the part of the physician (and less cost for the patient). Dark hair against pale skin often requires the most hair in the restoration process. Of course, a patient can simply lighten his hair to make the restoration look more full. One of the (few) benefits of aging is that it will accomplish reduced contrast between hair and skin all by itself.

Hair Character
Hair character is the second most important factor in determining the amount of hair restoration work needed. Curly or wavy hair produces a full appearance more easily than straight hair. African American hair in particular curls so that a single hair shaft covers more scalp with less hair length than straight hair. Strong, naturally curly hair that holds its shape tends to produce fuller results more easily than thin straight hair that falls flat against the scalp.

Hair Bulk
Hair bulk, or hair shaft diameter, contributes greatly to the visual impact of hair. Coarse hair has greater bulk and requires fewer hair follicles per square inch than fine hair to produce the same effect. Coarse hair usually grows naturally in smaller groups (follicular units) than fine hair and should be transplanted that way for the most natural results.

Hair Density
In the majority of patients who are candidates for a hair transplant, hair density (the number of hairs per cm2) varies from about 150 hairs/cm2 to over 300 hairs/cm2, with the average of about 200 hair/cm2. However, as previously mentioned, hair in the human scalp does not grow as single hairs, but in groups of 1-4 hairs. Interestingly, these naturally occurring groups (called follicular units (FU)) have a relatively constant density in the scalp of 100 FU/cm2. This means that the average follicular unit will contain from 2.0 hairs. Those patients who average 1.5 hairs per follicular unit will have a naturally thin appearance and therefore a thinner appearing transplant. Those patients who average 3.0 hairs per follicular unit (300/hairs per cm2) will have a fuller looking transplant.

How Many Grafts Will Make Me Happy?
When patients ask how many grafts it will take to make them happy, what they are really saying is, "give me back what I lost and I'll be happy." When this is the case, what the bald man really wants is unrealistic; therefore, one must address how much work needs to be done to make the patient satisfied. Satisfaction should be addressed in relative terms to make this problem understandable.

A man who is accustomed to his balding will be easier to please, and will accept a less full appearance than a young man who is starting to lose his hair and who remembers the days when he looked in the mirror and saw the vibrant, full hair of a teenager. The young patient wants his adolescent hairline and density back and will often be satisfied with nothing less. Since surgery is permanent, the hair-restoring surgeon must plan a hairline that will be appropriate for the patient's entire life and he must transplant a density that is consistent with long-term donor reserves. Because of these factors, some young patients are not good candidates for surgery.

The older patient with significant hair loss, on the other hand, will often be ecstatic with his mature hairline restored and a modest amount of natural-looking hair covering his head for the first time in years. For the majority of patients between these two extremes, the physician's careful guidance will help the patient understand what goals can realistically be achieved and whether hair restoration will be worthwhile.

With an understanding of human nature, hair dynamics, and practical issues, we have concluded that it is not always wise to recommend a specific number of grafts as though this number is an absolute amount. Instead, we often recommend transplant sessions of the greatest number of grafts that can be reasonably and safely moved within the confines of four important constraints listed below.

1. The patient's goals
2. The projected pattern of hair loss in a worst-case scenario, as determined by heredity, age and physical examination
3. The amount of hair in the permanent zone (donor area) that can be safely transplanted (this is related to a number of physical factors including donor density and scalp laxity and should be assessed by the doctor at the time of consultation)
4. Economic and time constraints of the patient

The Physician's goal is to help the patient understand how close he or she can come to meeting personal needs and expectations, how much the hair restoration will cost, and how many sessions it is likely to require. Do not start the hair restoration process unless you understand what it will take to finish it. With proper planning, satisfaction is easy to achieve.

Keep in mind that the transplantable hair numbers generally reflect an average amount of total hair that can be moved and applied to one's hair loss. This movable hair can be transplanted in one or multiple sessions depending on the four factors above and your doctor's skill and experience. For example, if procedures are limited to only 100 grafts each, then patients will be committed to an extended number of surgical sessions. Possibly not obvious at the onset, such extended treatment sessions often end with the patient losing interest. Financial or personal reasons may also cause the patient to fail to complete the treatment course. Just as important, multiple, small procedures move hair inefficiently and waste precious donor supply.

The impact of the transplant depends both upon the distribution of grafts as the absolute number used. Nonetheless, it is still useful for the patient anticipating surgery to have a general idea of the numbers required, both for the initial procedure and for subsequent sessions.

What Drs. Rassman and Bernstein recommend
Although there is significant variation from person to person, the average number of follicular units that we generally transplant in the first session for specific Norwood classifications is listed below. We first presented these numbers in our landmark 1995 publication "Follicular Transplantation." The recommend numbers have changed little over the years, except that with the implementation of stereomicroscopic dissection, we rarely need to transplant more than 2400 grafts in a single session. All "units" or "grafts" in this discussion refer to follicular units, not minigrafts or micrografts.

First Follicular Unit Transplantation Session

Norwood Class Follicular Units Total Units With Crown
3 800-1000+ ---
3 Vertex 800-1000+ 1100-1300+
3A 1300-1600+ ---
4 1100-1400+ 1500-1800+
4A 1700-2100+ ---
5 1500-1800+ 1900-2400+
5A 2000-2400+ ---
6 2000-2400+ 2400+
7 2000-2400+ ---

In general, the higher the donor density, the greater the number of hairs each follicular unit will contain. With low donor density, little scalp laxity or poor hair characteristics, these targets may not be achievable.

We generally do not recommend hair restoration surgery for Class 3 patients unless the hair loss is cosmetically very bothersome, the hair loss pattern seems stable, and the patient has excellent donor reserves. Often these patients have special circumstances, such as career demands, which require transplantation at an early stage. Medications are the best initial treatment, especially with early Class 3 patients.

The number of grafts required to complete the hair transplant process for a given Norwood Class may vary significantly from individual to individual. Nevertheless, it is helpful for someone anticipating surgery to have an idea of the number of follicular units that a typical individual would need for a complete restoration, both with and without crown coverage. (This data was published in Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatologic Surgery 1997.)

Total Number of Follicular Units Suggested for a Complete Restoration

Norwood Class Follicular Units Total Units With Crown
3 900-1500 ---
3 Vertex 900-1500 1300-2000
3A 1400-2200 ---
4 1200-2000 1700-3000
4A 1800-3600 ---
5 1700-3000 2100-4000
5A 2000-4400 ---
6 2200-4600 3000-5600
7 2200-4800 4000-6600

A satisfactory restoration does not necessarily mean that complete coverage of the entire bald area has been achieved. Finite donor supplies often limit what can be accomplished,

Hair Loss Research Home  | Top of Page  | Expectations  | Contact Us