View Full Version : Reliable Graft Count?

01-28-2010, 09:30 PM
I was wondering if the graft count they give your after the procedure is correct or do they tell you more to make you feel good about the HT.

I had a procedure 5 years ago and when I returned home from Miami the girl who cuts my hair counted about 1600 grafts, they told me 2120?
The doctor was nice and everything was some what professional. BUT are they (meaning all HT Doctors) telling us the truth when it comes to count?

Just wondering.


the B spot
02-03-2010, 07:38 PM
Happens a lot. It is an unfortunate dark side of the HT industry that clinics will tack on extra grafts to increase cost to the patient.

We use a digital counting device when Dr. Ron makes his incisions...that way the patient can actually see/hear the incisions as they are made and see the final result is in line with what we eventually harvest.

You will find clinics that have a long standing reputation for integrity do not have these type of questions asked.

Make sure you chose a clinic that delivers consistently.

Take Care,

02-05-2010, 12:16 PM
If any clinic were to cheat you, then they probably are going to cheat others and will eventually reflect in their overall long-term work.

There are many ways to be sure the graft count is in place. Most of the techs segeregate the grafts according to size and arrange them for count on that basis. They know at the end exactly how many singles, doubles, three's, four's etc that they have placed. Grafts are tracked by what was cut and what was placed and what was discarded.

02-09-2010, 07:22 AM
Ensuring you are receiving an accurate graft count is a valid concern for any hair transplant patient. When you are being charged by the graft for an expensive procedure, accuracy of the incision count is critical so that you know you are getting what you paid for.

As the_B_spot noted, a digital counting device is available to ensure the most accurate count possible. Device for Hair, LLC currently makes the only such device on the market: the patent-pending Counting Incision Device (C-ID). This single-use device was developed by Dr. John Cole and is available to all surgeons for $20. Dr. Cole designed this instrument with patients’ interests in mind, particularly after hearing concerns such as cleanerguy’s. Counting Incision Devices accurately maintain the incision count during recipient site preparation and display the count on a small LED screen.

A number of physicians have purchased Counting Incision Devices and we have received very positive feedback regarding such things as the accuracy, ease of use and the overall concept. It is important to note that these instruments are intended for single-use only as it is impossible to thoroughly and safely sterilize these devices due to the electronic circuitry involved. Therefore, a new device should be used for each new patient and disposed of following each procedure. At just $20 a piece, doctors making thousand per procedure should not have a problem using a new C-ID for each patient and disposing of them afterward.

Bottom line: The only way to know the precise number of grafts you receive is to demand that your doctor use a Counting Incision Device and show it to you following the procedure. You should also remember that each instrument is meant for one-time use only and ensure that your physician does not try to re-use a C-ID on you or others. To ensure safety and sterility, you can even purchase a C-ID for your own procedure at device4hair.com.

B_Spot: we're so pleased that Dr. Shapiro is happy with Dr. Cole's devices- we anticipate additional orders from him soon!

02-09-2010, 10:59 AM
That sounds like an interesting device. Any photos?

02-09-2010, 11:28 AM
It really is a great device, Winston.

I've attached a small image but you can also see a video of the Counting Incision Device being used during a procedure, in addition to product specifications, here: http://www.device4hair.com/C-ID-Revolutionary-Counting-Incision-Device-for-Hair-Restoration.html (note: this video shows the actual incisions being made and may be a little graphic for some).

02-09-2010, 11:38 AM
It really is a great device, Winston.

I've attached a small image but you can also see a video of the Counting Incision Device being used during a procedure, in addition to product specifications, here: http://www.device4hair.com/C-ID-Revolutionary-Counting-Incision-Device-for-Hair-Restoration.html (note: this video shows the actual incisions being made and may be a little graphic for some).

It looks like a home pregnancy test.:)

02-11-2010, 07:42 AM
Winston, I shared, with Dr. Cole, your comment about the CID resembling a home pregnancy test and he loved it. ;)

Dr. Cole had some (actually, many :)) thoughts relating to the need for a Counting Incision Device and its inception that he had his assistant transcribe so that we could share with forum members:

"When I first started performing hair transplants a little over 19 years ago, keeping up with our graft count in the recipient sites was not very difficult. This was because we typically only performed procedures of between 50 to 100 grafts. Within a few months of my introduction to hair transplant surgery, however, I recognized that the results of these larger mini grafts and plug graft transplants were aesthetically poor. Therefore, I began experimenting with smaller grafts and, by 1992, my procedures were predominantly smaller grafts, known as ‘follicular units’ today.

Of course, I called my grafts at that time ‘pilosebaceous units’, which is probably a more accurate nomenclature for these small grafts. This is because the term ‘follicular unit’ is actually a histological term. The term pilosebaceous unit is an anatomical term. Regardless, as I began performing grafts containing 1, 3, and 4 hairs in large quantities, the first problem I noted was that we had a tremendous difficulty maintaining an accurate count. When I began performing hair transplant surgery, I was involved in every aspect; I still think that this is extremely important in hair transplant surgery. I still believe physicians should be involved in graft cutting and graft placing. They need to know how to properly prepare a graft under a microscope; they need to know how to properly place a graft. The reason these things are so important is because physicians need to know how to train their staff. If you have rarely cut a graft, or if you have rarely placed a graft, you will never know if your staff is doing it properly. Unfortunately, this is the case with far too many practices today, and has been for years.

As my graft counts exceeded 200, 300, then 600 and up, accuracy became an increasing concern. In those years, there was no system to accurately monitor the counts. There were some practices that were using a foot switch to count the recipient sites they made. This involves stepping on a pedal every time they made a recipient site. The problem with this is that one has to move the foot at the same time as the hand, and this can result in a degree of inaccuracy. Furthermore, if one accidentally steps on the pedal, then the count is inaccurately elevated.

As I stated, I spent a tremendous amount of time cutting grafts over the years. In fact, for many years I would average cutting 1000 grafts with every case, and placing 1000 grafts with every case. I can tell you from experience that when you cut grafts under a microscope, you encounter a number of distractions: you will often have a television going, patients will ask questions, staff members will need certain directions, etc. These distractions in the middle of graft counting can result in inaccuracies that occur repetitively during the day. Moreover, sitting under a microscope all day cutting grafts for 4, 5 or 6 hours at a time is a dull, monotonous process. It is very easy for technicians, who have a limited investment in the accuracy of the graft count to begin with, to become distracted. Minds can stray from monotonous work, and before you know it, their graft counts can be off by 100 or more grafts.

For this reason, I have always felt that the most accurate way to keep up with our graft count is for the physician to be extremely accurate with the number of recipient sites that he makes. Therefore, I have always made my recipient sites with the help of an assistant. We would both count simultaneously while I made the recipient sites. I would mark on my glove or a sheet of paper every time I made 100 grafts. The problem with this is that we would both become distracted with events in the room, something that was said on the television, or by something that the patient said. Most frequently, it was interruptions from the patient that created the greatest distraction for both of us. For example, if the patient needed something or he wanted to discuss something about the procedure, I would be inclined to respond to him. Of course, when I responded, I would often times return to the count and have to ask my assistant where we were with the count. Unfortunately, sometimes the assistant was distracted as well, and we were both confused about the count. Therefore, it was my general rule to revert back to the lowest absolutely known count so that we didn’t inadvertently overcharge our patients for the number of recipient sites we made or the number of grafts we performed.

Now of course, we would have our graft cutters count their grafts and I would count my recipient sites and then we compared notes and attempt to be as accurate as possible with the number of grafts we made. The problem was that the two rarely were an absolute match. This was because there is a high capacity for human error with both cutting grafts and making recipient sites.

Despite the fact that counting our recipient sites is more accurate than the process of counting our grafts, I recognize that we were often inaccurate. Therefore, I developed a device which I call the Counting Incision Device, or CID. This device accurately maintains the recipient site count that is made into the skin. It is the most accurate means for us to keep up with our graft count. In fact, it is the only accurate means for us to keep up with our graft counts.

The Counting Incision Device, or CID, makes an audible beep with each recipient site. The count is accurate to several thousand grafts; it can record recipient sites in excess of 10,000 if it were possible to do this many. Each device is tested for accuracy prior to packaging and sterilization.
The device is an electronic circuit and is disposable, as it is intended for single use only. The reason that I made this device disposable is that it is impossible to re-sterilize the electronic circuitry, and it is impossible to thoroughly clean the device after use. There are a number of small nooks and crannies in this device, where a scrub brush simply cannot get. It is impossible to wipe down all of these nooks and crannies with an antiseptic towel. Similarly, because of the electronic circuitry, it is impossible to place the device into an autoclave or soak the device in a solution, such as Cidex, to sterilize it over night. Therefore, it is absolutely mandatory that physicians dispose of this device after every use. If they use this device on more than one patient, they are putting patients at risk of infection by some very serious diseases."

02-11-2010, 05:05 PM
I’m glad Dr. Cole has a sense of humor!:) His device does seem very valuable.

02-15-2010, 07:29 AM
Some more thoughts on graft incision sites and the CID:

There are many different instruments surgeons can use to make incision sites. Today, most physicians use custom-made blades or needles.

Dr. Cole began using custom-made blades back in 1991. He found them to have advantages over cutting ‘holes’ in the heads of his patients (back then, most physicians used punches to cut holes for the grafts). Many did this even with follicular units. The problem with the holes was that they caused too much tissue destruction. The other problem was that if you cut a core of bald skin out, you might also be removing miniaturized hair follicles that might one day be turned on by some revolutionary medication. Therefore, Dr. Cole abandoned the use of punches many years ago and became one of the first to use custom made blades with depth control as early as 1991.

Many physicians feel that the size of the recipient site needs to be as small as possible. A general rule in cosmetic surgery is that if an incision is less than 1.5 mm in length, it should heal without a visible scar. Indeed, only rarely will you see, even a barely visible light line of hypopigmentation when you use custom-made blades that are 1.5 mm or less in length.

Today, many physicians feel that recipient sites need to be very small. This is a double edged sword, however, because a very small site will compress a graft and may strangulate the graft so that it will not survive. A single hair graft is usually 0.4 mm in diameter without any adipose around it. With adipose, the graft will be slightly greater in diameter. A two hair graft will be at least 0.8 mm in diameter. If any surrounding tissue remains on the graft, the diameter will be greater. If the graft has a certain diameter and it is placed in a recipient site that is smaller, the graft will exert outward pressure on the tissue. At the same time, the tissue will exert pressure on the graft. This could result in destruction of the graft if the forces are too great.

Regardless of the graft size of the size of the recipient sites, it is very important to have an accurate count of the recipient sites. The only way to ensure you have an accurate count is through the use of the Counting Incision Device, or CID, that Dr. Cole developed and patented. We encourage all physicians to use this device simply because it is the only way you can truly be accurate in your incision site count. There is no reason to make more cuts in the skin than you have grafts to place. Furthermore, patients deserve to pay only for the number of grafts that are placed.

Don’t forget: the CID is a single use instrument that should be disposed of after each procedure.

02-22-2010, 08:39 AM
Over the past year, many physicians have expressed an interest in the Counting Incision Device. It truly is the best solution to keep track of your graft count. There are a number of physicians currently using the device. These doctors appreciate the accuracy of the device, along with the freedom to focus on their surgery rather than on the graft count. An accurate graft count is very important, not to mention that the capacity to focus on the surgery (and not a three or four figure count) really does improve the overall transplant quality.

Some clinics ask the patients to count the incision sites as the physician makes each cut in the skin. Each time the physician makes the cut, the patient can hear a sound similar to a crunch. The intensity of the sound varies depending on the instrument used by the physician. Custom made blades are notorious for making the loudest sound. When the patient counts the sites, the physician is freed to focus on the surgery. Unfortunately, studies show this is the least accurate means of counting graft sites. It stands to reason that patients, who are not experienced in counting incision sites, are the least prepared to keep up with this very important aspect of the hair transplant procedure. Patients get distracted just like anyone would so counting into the thousands can easily result in a disparity in the hundreds.

Freedom to focus and an accurate incision site count are the two most important reasons that all physicians should use an accurate automated counting system. Currently, the patent-pending Counting Incision Device (CID), developed and patented by Dr. Cole, is the only device capable of meeting both of these two important functions.

Dr. Cole insists that each device be disposed of after a single use with an individual patient. The electronics make the device impossible to adequately clean and sterilize. Enclosed are some close up photos showing blood from a procedure on the Collete and other places. These small crevices cannot be reached adequately for scrubbing. Furthermore, because this device is made of plastic and has electronic parts, it cannot be sterilized properly. This is why it is so important that CIDs be disposed of after each patient.

We hate to say it, but some physicians are more worried about their bottom line than proper sterilization. It really is up to the individual patient to insure that his physician is using a properly sterilized CID rather than one, which was simply wiped off and then had the tip (only) placed in Cidex over night. The latter simply is not adequate and will result in potential risk to subsequent patients. We hope these photos will make you aware of just how important it is to use properly sterilized instruments.

The CID is the best method for accurately monitoring the incision site count. We think all physicians should be using it in an effort to improve patient care. We are concerned, however, that some physicians will not properly sterilize their instruments. Therefore, it is imperative that you, as patients, recognize the need to have a new instrument for each patient. If you would like your physician to use this instrument in your case, simply have him call us at (800) 368-4247, or we will be happy to sell a sterilized instrument directly to the consumer for use in your procedure (this way you know that the instrument used for you is sterile).

03-29-2015, 03:48 AM
Now why would incision count be an accurate way to count transplanted grafts? Seems to me that the number of transplanted grafts could be much less than the actual incisions made in preparation for inserting the transplanted hair. Example: you could make 2000 incisions and only implant 1800 hairs and the patient would never know.

Rashid Rashid, MD, PhD
03-29-2015, 05:41 AM
One way to do this is to have 2 different techs count the grafts before placing, and the physician count the sites as they are made (we do the dash per 100 mentioned above).

It would be hard to find 3 people get it wrong unless the clinic is shady. Another factor is time. Procedures rarely take less then 3-4 hours( usually excluding time taken to eat) and we have seen patients claim they went to clinic X and got 3k FUE grafts in 2 hours start to finish which is hard to believe.

Finally, you have to also consider the benefit of doubt to the clinic. Survival of grafts can be an issue. Graft survival is not always 100% and factors affecting survival are many. Just a few
-Graft handling in procedure i.e extraction/placing
-Graft storage in procedure
-In some cases, when a patient has many single hair very fine grafts, a clinic will sometimes put 2 grafts in a site to dry to increase density behind the hair line and avoid an overall super thin look...even though it will still be thin due to less overall sites. But in this case, when you count sites you are not counting every graft.
-Some patients move and talk a lot in a procedure making it very hard to carefully and gently implant grafts and even harder to do FUE extraction
-After care - We sometimes find patients accidentally scratch out grafts in the first night or so. Also, we have found patients accidentally bump their heads the first day or so. Often a detailed history during early follow ups will reveal many post op care unintentional mistakes despite careful review with the patients. Remember, the patient doesnt do post op care regularly and the most OCD tend to get the best results.