Ultra dense packing has been a controversial subject among the medical fraternity for various reasons. On the positive side, ultra dense packing can help achieve natural density in one session, limiting morbidity and saving a lot of money and time for the client.
On the negative side, there are concerns with donor depletion, limiting availability for future sessions and also the practical aspects of the procedure can be very challenging. Besides this, there is the misconception about poor uptake with ultra dense packing.
There are some issues that are addressed with the development of the 3G FUE Restoration technique. We have known for years that more hair per graft (chunky grafts) yields better density than placing a lot of fine grafts. Let’s compare this concept to a garden: If you have a similar sized garden, you can either try to populate it with a lot of twigs, risking poor uptake or use a few twigs and plenty of trees to achieve respectable coverage.
A close inspection of the donor area reveals that there are a mixture of grafts of different sizes, namely two’s, three’s and four and five hair grafts. This mix makes the donor area look very dense and also very natural. Now if we apply a similar concept to the recipient area, there is no reason why this cannot be achieved.
However, there are a few technical issues associated with the recipient area that makes ultra dense packing a bit challenging. Firstly bald skin is exposed to sunlight and there are always issues with chronic sun exposure that makes the skin a bit harder than hair bearing skin. Secondly, bleeding is more of an issue with the recipient area causing the flushing away of grafts.
To counter the difficulties, what we tend to do is to phase the procedure over a couple of sweeps. A closer inspection of the recipient area reveals the pores and hair bearing skin. There is convincing evidence to support the fact that the stem cells go dormant rather than die. From experience, we have realised there is a zone of least resistant both around the graft and hair bearing skin. We capitalize on this concept by using instrumentation that precisely fit the size of the grafts, both during extraction and placement. This makes us achieve grafts with no transaction and also graft of different sizes. We can utilise a similar concept while placing, by making incision in the area of least resistant. Incisions are made to fit the size of the graft that also adds specific angles. Ultra dense packing can be achieved in one single session.
We use two methods of placement:
Another trick we employ is doing the placement over three sweeps. During the first sweep we tend to place the chunky grafts at random intervals and let the skin heal while we extract more. This ensures that the grafts don’t stay out the body longer. This in turn allows the grafts to bed into the fine incisions. Now the same process is repeated during the second sweep. For the third sweep we use a Choi implanter to place mostly two-hair grafts. This in turn prevents dessication and also you achieve an advantage mechanically that there is no popping of graft and minimal bleeding. Lastly, the use of Acell prevents neogenisis (new blood vessel formation). This in turn makes sure there are better uptake of grafts.
Using this technique, ultra dense packing can be achieved in one session without causing a lot of (eyelid) swelling. However, caution should be exercised in patient selection in order to prevent donor depletion in patient with unstable hair loss.
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