Read Dr. Wolf’s medical journal writings on incisions and graft placement:
The Art and Craft of Recipient Site Creation and Graft Placement ARTICLE
Incisions Placing Abstract ARTICLE
Email Exchange on Graft Placements
Dr. Wolf and a prospective patient named Daniel share a thoughtful exchange below, on Dr. Wolf’s participation in hair graft placement. Most physicians rely heavily on assistants for this activity during surgery.
Read and learn, and see why Dr. Wolf is unique among his peers!
If you have a hair related question for Dr. Wolf, please fill out the “Question for Dr. Wolf” form at the bottom of this page. This engaging email chain began with a website form submission. Our clinic is passionate about hair transplant technique, and we enjoy sharing expert knowledge with any interested audience.
Dr. Wolf, I was looking over the pictures on your website, and I noticed that a large number of the patient photos describe the hair-transplant procedures as having taken place over two or three days. I’m not familiar with any other surgeon who does it that way (i.e., not performing the entire transplant in one session). I’ve never even heard of a hair transplant session being performed over the course of several days. Please do not take this email the wrong way. This is not a complaint, and I have no issue with you doing that way if that’s how you choose to perform your surgeries, but I would like to know the reason why you choose to do them (or at least a large number of them) that way, though. Is there some kind of benefit to the patient for doing that way — or, perhaps, some kind of a benefit to your or to your staff? If yes, please explain. I’m really curious about this.
DR. WOLF RESPONSE:
Daniel, Thanks for contacting me. Some of the photos are from the past when we did fewer grafts per day — especially when we were doing FUE by hand. We now use a mechanical device for FUE so we are faster. The patient who needed three days had severe scarring and large grafts from prior, outdated procedures. A mass redistribution was done using FUE in which large grafts from the past were debulked and retransplanted, new grafts were taken from a very limited donor area, and some grafts were placed into prior strip scars. Repair cases, when done correctly, often take longer.
In general at this time we can do 2000 strip grafts in a day, to have more done it would take a second day. We can do 4000 grafts in two consecutive days. For FUE we can now do 1000-1200 grafts in a day, so 2000 would take two days. I have a small staff and specialize in custom, high quality work. An assistant and I place all grafts. Fewer than 20% of doctors doing hair transplants do ANY placement at all; few, if any other than me, place 50% of all grafts. Everything we do is to maximize graft survival and to get as close to 100% growth as possible. We do one case a day and are not interested in seeing how many cases or grafts we can do in a day. Please let me know if you have additional questions.
Bradley Wolf M.D.
Dr. Wolf – Thank you for your reply. Your reply was very informative, and the information that you supplied was very good to hear. I most definitely will be seeing you as soon as I am ready. You’re not planning on retiring anytime soon, are you? I’ve always felt that hair-transplant surgeons should be more involved with graft placement, and I’ve always thought that it was kind of “funny” when various doctors are praised for their work when, in fact (from my point of view, at least), they do very little of the actual work and that, in many cases, it’s the skill of the technicians who determine the final results.
Ha, I even wrote to a letter to (Dr. M) on his Blog a while back on this very subject. In his response to my question, he does a very good job in explaining why he thinks it’s actually better for the technicians to do the work. Although I respect Dr. M very much and truly think that he’s one of the good guys in the industry, I’m sure there’s a fair amount of “spin” in his response.
DR. WOLF CONTINUES:
Daniel, I read Dr. M’s reply over the weekend. I know him very well and we basically have the same philosophy on most hair topics. I did big cases 2500-3000 in one day but since I have a small staff, it took too long. I’ve gone back to doing smaller cases, a max of 2000 a day and we generally don’t do over 1800 in a day because this takes us all day. I’m pushing the envelope to see how perfectly we can place the grafts. My other assistant who places has been working with me for over 12 years. We have each placed well over 1 million grafts.
I could go on and on about the nuances of making incisions and placing grafts; but the short version is that the person who controls the grafts controls the result. It’s fairly easy to cut grafts out of a strip under a 10X microscope. Even the first day, new assistants can identify follicular units and make pretty good grafts; they are just slow in doing it. It’s a finite task. They can see the FUs. As they get better they cut them smaller and faster. Some clinics (one chain I know specifically) pays cutters by the number they cut. They get paid more if they cut more; never in my clinic.
But with placing grafts there are a lot more nuances that can affect the survival of the follicles and the quality of the result. After a graft is placed, only the placer knows how well it was placed and if there is damage to the bulb under the skin. The only way to check all the grafts is to take them out. If I did this, their survival would be greatly reduced, as there is only one chance to get the graft in and have the least amount of trauma. Every successive try can cause more damage.
We practice graft grading and differential placement, meaning we put the best grafts in the location where they will have the greatest impact. All grafts are not equal…and every one or two or three hair grafts are not equal. For instance, we put the best “one” hair grafts in the leading edge of the hairline, not too thick and with a 100% certainty of survival. One hair grafts that are thick shafted would be put one or two rows back. One hair grafts where survival is questionable are either discarded, put aside for the end (not put in the hairline) or put in an area not very visible. Same with two and three hair grafts. And if a graft is damaged when placed, which can happen, we take it out and discard it or put it in a less visible area. Absolutely everything is done to ensure the best growth and best result with each graft.
I make all incisions and make sure the width and depth of the incision is as perfect as possible. Different sized incisions are used for one, two, and 3-4 hair grafts, always. Sometimes with a great variation in graft size, I’ll use two blade sizes for one sized grafts, like 1.0 and 1.1 mm wide incisions for two hair grafts. That way a small two can be put in a 1.0 and a large 2 or small 3 can be put into a 1.1. Some doctors actually use one incision size and no depth control. Some doctors can make 2000 incisions in 20 minutes. It can take me 3 hours to make 2000 incisions all with the perfect depth, width, and angle to allow perfect placement.
So Dr. M is giving his opinion. I am seeing how far I can push the quailty aspect and don’t trust anyone except me and my assistant to put in grafts. We may charge more than some – that’s because we do only one case a day and it always takes all day. It takes 12 hrs to do 1500-1800 grafts. I am patient and like placing, especially if I can attain the best results ever contemplated. It’s better to do 1500 grafts and get 100% to grow than do 3000 and have 50% grow. A lot of doctors are doing huge sessions without measuring survival rates. If one does 4000 grafts and 2500 grow, that’s only 62.5%. But 2500 is still a lot of grafts and hair. I see photos of results with huge number but often seriously doubt if as many grew as were placed.
Anyway, those are some of my thoughts about placing. We are trying to do it as well as it can be done. Not that others aren’t, but that’s how we do it. I have no one telling me how to do it or how many grafts or patients to do in one day. So I can take as long as I want, and I do.
Hope that answers some of your questions.
Bradley Wolf M.D.
Dr. Wolf, thanks for your very nice response. I not only appreciate you taking the time to read Dr. M’s reply, but I especially appreciate your detailed and thorough response to his comments. I was only expecting to receive a brief reply, if any. But you went above and beyond my expectations, and I am very grateful. Reading your response, I sense that you are very detail-oriented and a perfectionist who likes to be very much in control. That’s a very good thing, and it’s exactly what I’m looking for.
So, based on your detailed response to my questions, and based on your description of how you run your practice and perform your surgeries, I feel extremely confident and comfortable in coming to see you when I am ready. Initially, I was planning on having at least two consultations prior to having anything done. It was always my intent to come in and see you, but I was also planning on going to New York to have a consultation with (another Dr.) as well, but that won’t be necessary anymore.