I would be happy to give my perspective as well as comment on some of the issues and concerns associated with larger sessions. But first, I want to make clear from the outset that this commentary should not be construed as criticism of H&W. They do great work. I have been fortunate enough to see their work personally when Dr Shapiro sent me to visit their clinic. Our clinics are very similar with respect to the core components of hair transplantation, which include meticulous skill and quality control at every step of the procedure. More specifically these core components include:
Microscopic creation of grafts with no waste, and every assistant using microscopes.
The careful and deliberate creation of ultra fine recipient sites made with sharp custom made blades ranging from .6 mm to 1mm.
The use of tumescence and magnification when creating recipient sites in order to protect the blood supply as well as limit trauma when going in between native hairs
Skillful placing of these tiny grafts into these tiny incisions efficiently with as little trauma as possible. This is a critical step and often the Achilles heel of many clinics
A final core component is having the artistic skill and knowledge that allows the physician to use these grafts to mimic the natural patterns and distributions of hair that occur in nature. Dr Shapiro often uses the analogy that these small micrografts can be thought of as tiny paintbrushes with which one can do very specific and delicate work. But having the paintbrush is not enough…one needs to know how to paint.

As I stated above, H&W’s clinic is very similar to ours with respect to these core components. However, our perspective and feelings about the role of the “ultra” large session varies to a degree. Larger sessions have their place and can be very successful as long as performed properly. And more importantly, the patient is a good candidate for the technique. We have done sessions of 4000 to 5000 with excellent results. However, one has to remember that there are also patients that either don’t need or are not good candidates for larger sessions. It is also important to point out that the POTENTIAL for certain problems occurring during a hair transplant (such as wider scars, greater shock loss, and decreased growth,) increase as sessions get larger. With modification of technique and great care this increased POTENTIAL can be controlled to some degree but not completely.

One reason it is hard to get a consensus on the risk for larger sessions is that too often too wide a range of session size are all lumped into the same category of “ultra” or “super” mega sessions. Lumping all larger session into one group is really misleading as they are not all the same. A 3000-4000 graft case is not the same as a 5000 graft case, which is not the same as a 6000 graft case. In general, as the case gets larger the potential for problems increase.

There are many factors to consider when a physician contemplates performing the new “ultra mega session”. One of the main factors is whether or not a patient is a good candidate. Among the things you have to consider are:
The donor density, donor laxity and potential for scarring. In addition, you have to consider the patient’s degree of concern about the possibility of a scar. No matter how good the physician and his ability too create small scars, the wider the strip the more POTENTIAL for a wider scar.

The amount of pre-existing native hair in the recipient area and the risk of shock loss has to be considered. Larger sessions increase the chance of damaging native hair. We have helped decrease the risk by using tiny blades, tumescence and magnification, but the potential still exists and increases as the number of incisions increase.

The patient’s age , current balding area and potential for future balding has to be considered. The younger the patient and the more uncertain one is of the final degree of baldness the more careful you have to be about using up a large percentage of donor hair early. If you use up too much donor early you may not have enough donor left to blend the pattern when future hair loss occurs. Most patients receiving session over 4000+ are doing both the front and part of the crown area. When doing just the frontal area the numbers are lower….especially if there is pre-existing hair in the area. When doing someone with a wide open bald area in the front and crown with plenty of donor the numbers get higher

With all things considered, the number of ideal candidates for the ultra large sessions is lower than you expect. I believe those who are not good candidates are often disappointed when told they should have more moderate sessions because they have been led to believe by the internet that ultra mega sessions are the standard rather than the exception. I don’t believe this perception was intentional but was just a by product of the larger more news worthy procedures being reported over the more standard ones. I believe that if you asked physicians known for being able to do the larger sessions that they would still say that a significant number of their cases are more moderate for one reason or another.

There are a few other points I would like to bring up about doing the larger sessions.

From my experience as a technician, the larger session can take quite a bit longer than more moderate sessions…often up to 10-12 hours. These 12 hour days are hard not only on the grafts, but also on the technicians cutting and planting all the grafts. It’s unrealistic to think there won’t be fatigue or burn out factor happening with the mega sessions. On days when one of the key assistants is sick or missing, this issue can be even more important.

I’ve found that a patient who has donor density of 100-120 grafts per cm2 is above average rather than the norm (avg. seem closer to 85-90 cm2 for our clinic because we keep all the natural groupings intact).

When a donor strip is cut, we keep the natural groupings intact and our donor strips yield the standard FU distribution. We are able to provide the graft and hair count to every patient simply because we record each graft as its cut on our “cutting sheet”. We feel it is important to keep track of the grafts in the categories of 1’s, 2’s, 3’s and 4’s for a number of reasons. First of all, this info helps the doctor determine the size of the blades for incisions as one hair graft would need a smaller size blade than a four hair graft. It also lets us calculate the exact hair count, which is a much more accurate reflection of what a patient is receiving than graft count. Since about 35% of the grafts should be 3’s and 4’s, the graft count would be about 35% higher if the majority of these were converted to 1 and 2 hair grafts. In other words, a 3000 graft case with all the 3 and 4 hair grafts intact would be equivalent a 3900 graft case when the majority of the 3 and 4 hair grafts have been converted to 1’s and 2’s. Similarly, a 4000 graft case with 3 and 4 hairs intact would be equivalent to a 5200 graft case when the majority of the 3 and 4 have been converted to 2’s and 1’s.

There is still a question about decreasing yield when transplanting densities over 30 to 40 fu/cm2. I know Dr. Shapiro worries about this and says that at this point we just don’t have enough data. Every now and then he sees patients that were supposed to have very high densities that just does not look as high as he expected. It is deceiving because the patient is happy and looks good, and does not notice anything. He may have been transplanted with a density of 50 fu/cm2, but when examined it looks closer to 40 fu/cm2. Dr Shapiro worries that if this is really happening, we are potentially wasting some donor in these patients.

This leads to the last real question with regards to putting into perspective the role of the ultra large mega sessions (for me this is 4000+). From clinical observation, MOST patients (when doing the front, midscalp, and part of the crown) seem to be happy when they receive between 5500 to 6500 FU. If this is true, what is the real clinical advantage of getting these grafts placed in two sessions of 3000 vs. one of 5500 session? Is it worth the increased risk of problems to maybe save one surgery session?

Dr. Shapiro, in my opinion, has gradually increased the donor strip sizes to coincide with his comfort level, not because of the pressures of other clinics doing higher numbers or the patient wanting higher numbers. His current comfort level is 3-4500 graft sessions after careful consideration and only in patients that are ideal candidates. He’s always been about “what is best for the patients”; therefore, I will always trust and respect his judgment.