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Some additional info about larger sessions:
The average number of follicular units in a typical donor area is 16,600, within approximately 203 sq cm of surface area. It’s important to customize each transplant to the patient. If someone is Norwood Class V, they have about 180 sq cm of hair loss, class VI may have 220-250 sq cm of hair loss. Mathematically, it is sometimes impossible to deliver a reasonable degree of coverage in these individuals. When Dr. Cole performs a procedure, he first assesses what the patient wants, and then determines if it is possible to actually deliver what he wants. If the patient’s expectations exceed what is reasonable, it’s in the best interest of everyone to avoid surgery. If he determines that the patient has realistic expectations based on their degree of hair loss and their overall donor capacity, he will consider an approach to the donor area that allows him to provide the maximal benefit with the greatest aesthetic result.
If someone has enough hair loss to require 5,000+ follicular units in a single procedure, they may or may not be good candidates for hair restoration surgery. Someone who would require this many would likely be somewhere between a Norwood V and VI. It’s important to keep in mind that the one absolute, when it comes to hair restoration, is that hair loss is a progressive condition. Therefore, the approach to the patient needs to take this into account. Even though someone is an acceptable candidate for 5,000 grafts in a single procedure, a procedure will not necessarily be in the best long-term interest of the patient. For example, for a patient in their late twenties, or early thirties, and already showing class V with potential for class VI hair loss, adding hair to the crown area will likely result in isolated hair in the center of the crown, with a perimeter that lacks hair coverage in years to come. Removing 5,000 grafts today significantly depletes available donor supply for the future. Obviously someone who starts out with 20,000 follicular units today is going to be a much better candidate for additional coverage in later years; unfortunately these individuals are not the norm.
When Dr. Cole plans to maximally harvest a donor area in the initial procedure via FUE, he typically removes somewhere between 20 and 25 percent of the available follicular units. On an average individual, this would be somewhere between 3,000 and 4,000 grafts in a single pass. It is certainly possible to harvest a greater percentage than this, yet it is commonly not in the best interest of the patient. Consider that treatment of the frontal area, by itself, will maximally take somewhere between 2,000 and 3,500 grafts in a single pass. The objective many times is to focus on the front with the hope that restoration of coverage here will reduce an indiviudal’s concern about hair loss in their vertex/crown region. If Dr. Cole is successful in achieving a degree of satisfaction with a focus on the front, he has succeeded in reducing overall cost for the patient, and the potential pitfalls of opening the “Pandora’s box” of grafting the crown. This is a conservative approach and one that is generally in the best interest of the patient and that works best. Such an approach also leaves a “safety net” of donor hair for future procedures should the patient desire additional work in the frontal area to maximize density or fill in progressive hair loss, such as at the lateral rims of the scalp. The danger in trying to create maximal density in an individual who’s heading towards a Norwood VI is that they might end up having the isolated frontal forelock, similar to Joe Biden. This would obviously not be in the best interest of the patient and frankly looks unnatural (this is not a typically naturally occurring pattern of hair loss). Another approach to the crown area involves adding light coverage to make it appear that the patient is losing hair, rather than to try maximally cover crown. Such an approach allows an individual to maintain a normal appearance as they mature and continue to lose hair. Essentially, just because you can do 5,000 grafts does not mean you should, and Dr. Cole more typically takes a conservative approach.
In the photographs we posted, only one individual had 5,000 grafts in a single pass; the other two had multiple procedures to reach their total graft numbers. The patient who had 5,000 grafts at once was an older gentleman and his hair loss pattern was more stable based on his age (he was a Norwood VI). The patient who had 5,700 grafts was also a Norwood VI and he had two procedures to achieve this number of grafts; because he was younger, the approach was more conservative initially. The patient who had 9,200 total scalp grafts was a Class III Vertex who progressed to a V over a number of years. Hair was added throughout the top of the scalp in multiple procedures dating from 2003.
The overall objective with FUE is to gradually thin out the donor area so that the overall density in the donor and recipient areas become more similar. We find this to be a more natural approach than cutting out a large strip of hair-bearing scalp, as strip surgery involves. Also, with strip surgery, the available donor area is only about 160 sq cm, because you can’t harvest from the nape of the neck without leaving too wide of a scar (with FUE, on the other hand, you can typically harvest from over 203 sq cm of donor hair). It is perhaps even more important to err on the side of caution when it comes to large sessions via strip. Assume you have 80 follicular units per sq cm of scalp. If your surgeon were to remove 5,000 grafts, 62.5 square centimeters would be needed to achieve this, which would leave you with only 100 sq cm of un-harvested scalp (and a linear scar right in the middle).
The average number of follicular units in a typical donor area is 16,600, within approximately 203 sq cm of surface area. It’s important to customize each transplant to the patient. If someone is Norwood Class V, they have about 180 sq cm of hair loss, class VI may have 220-250 sq cm of hair loss. Mathematically, it is sometimes impossible to deliver a reasonable degree of coverage in these individuals. When Dr. Cole performs a procedure, he first assesses what the patient wants, and then determines if it is possible to actually deliver what he wants. If the patient’s expectations exceed what is reasonable, it’s in the best interest of everyone to avoid surgery. If he determines that the patient has realistic expectations based on their degree of hair loss and their overall donor capacity, he will consider an approach to the donor area that allows him to provide the maximal benefit with the greatest aesthetic result.
If someone has enough hair loss to require 5,000+ follicular units in a single procedure, they may or may not be good candidates for hair restoration surgery. Someone who would require this many would likely be somewhere between a Norwood V and VI. It’s important to keep in mind that the one absolute, when it comes to hair restoration, is that hair loss is a progressive condition. Therefore, the approach to the patient needs to take this into account. Even though someone is an acceptable candidate for 5,000 grafts in a single procedure, a procedure will not necessarily be in the best long-term interest of the patient. For example, for a patient in their late twenties, or early thirties, and already showing class V with potential for class VI hair loss, adding hair to the crown area will likely result in isolated hair in the center of the crown, with a perimeter that lacks hair coverage in years to come. Removing 5,000 grafts today significantly depletes available donor supply for the future. Obviously someone who starts out with 20,000 follicular units today is going to be a much better candidate for additional coverage in later years; unfortunately these individuals are not the norm.
When Dr. Cole plans to maximally harvest a donor area in the initial procedure via FUE, he typically removes somewhere between 20 and 25 percent of the available follicular units. On an average individual, this would be somewhere between 3,000 and 4,000 grafts in a single pass. It is certainly possible to harvest a greater percentage than this, yet it is commonly not in the best interest of the patient. Consider that treatment of the frontal area, by itself, will maximally take somewhere between 2,000 and 3,500 grafts in a single pass. The objective many times is to focus on the front with the hope that restoration of coverage here will reduce an indiviudal’s concern about hair loss in their vertex/crown region. If Dr. Cole is successful in achieving a degree of satisfaction with a focus on the front, he has succeeded in reducing overall cost for the patient, and the potential pitfalls of opening the “Pandora’s box” of grafting the crown. This is a conservative approach and one that is generally in the best interest of the patient and that works best. Such an approach also leaves a “safety net” of donor hair for future procedures should the patient desire additional work in the frontal area to maximize density or fill in progressive hair loss, such as at the lateral rims of the scalp. The danger in trying to create maximal density in an individual who’s heading towards a Norwood VI is that they might end up having the isolated frontal forelock, similar to Joe Biden. This would obviously not be in the best interest of the patient and frankly looks unnatural (this is not a typically naturally occurring pattern of hair loss). Another approach to the crown area involves adding light coverage to make it appear that the patient is losing hair, rather than to try maximally cover crown. Such an approach allows an individual to maintain a normal appearance as they mature and continue to lose hair. Essentially, just because you can do 5,000 grafts does not mean you should, and Dr. Cole more typically takes a conservative approach.
In the photographs we posted, only one individual had 5,000 grafts in a single pass; the other two had multiple procedures to reach their total graft numbers. The patient who had 5,000 grafts at once was an older gentleman and his hair loss pattern was more stable based on his age (he was a Norwood VI). The patient who had 5,700 grafts was also a Norwood VI and he had two procedures to achieve this number of grafts; because he was younger, the approach was more conservative initially. The patient who had 9,200 total scalp grafts was a Class III Vertex who progressed to a V over a number of years. Hair was added throughout the top of the scalp in multiple procedures dating from 2003.
The overall objective with FUE is to gradually thin out the donor area so that the overall density in the donor and recipient areas become more similar. We find this to be a more natural approach than cutting out a large strip of hair-bearing scalp, as strip surgery involves. Also, with strip surgery, the available donor area is only about 160 sq cm, because you can’t harvest from the nape of the neck without leaving too wide of a scar (with FUE, on the other hand, you can typically harvest from over 203 sq cm of donor hair). It is perhaps even more important to err on the side of caution when it comes to large sessions via strip. Assume you have 80 follicular units per sq cm of scalp. If your surgeon were to remove 5,000 grafts, 62.5 square centimeters would be needed to achieve this, which would leave you with only 100 sq cm of un-harvested scalp (and a linear scar right in the middle).
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