Dr. Keene and her staff are dedicated to patient satisfaction. All patients are encouraged to schedule follow-up appointments—either in person or virtually, at 4, 8, and 12 months. These visits are an opportunity to address any questions or concerns with Dr. Keene directly and to allow her to assess your results. Please don’t hesitate to call and book your follow-up appointments—we’re here to support you!
We also want to address why Dr. Keene doesn’t automatically recommend the highest number of grafts possible to maximize density in a single procedure. Patients need to understand that limiting graft numbers is not about being incapable of providing those numbers, or a strategy focused on forcing patients to do more surgery. Instead, it is about judicious donor management for what is often a limited resource, how to make less look like more, graft regrowth rates based on recipient site density, and at times assessing the best place to augment density once a patient knows what their new hair looks like and how they wish to wear it.
Dr. Keene’s Expert Approach to Hair Restoration
In Dr. Keene’s own words, determining the ideal graft density per square centimeter is both an art and a science, tailored to each patient’s unique needs, hair characteristics and goals. If every patient had identical hair loss risks, hair characteristics, and an unlimited donor supply, we could simply aim for the highest density in every square centimeter of hair loss for optimal aesthetics and optimal graft survival. (Studies show graft survival rates above 90% at 30–40 grafts/cm² by maintaining minimal out-of-body time and excellent hydration, though survival may decrease at higher densities.) However, the reality of lifelong donor limitations, which may only become clear years after a patient has had surgery, makes this decision far more multifactorial and nuanced, requiring careful consideration. Failure to consider the future can impact patients a decade or even a few years after over-aggressive approaches have depleted donor areas.
What Nature Teaches Us
Dr. Keene’s research, including a published survey, found that natural hairline density in men with no personal or family history of hair loss ranged from 28–55 follicular units/cm², with an average near 40. With this in mind, Dr. Keene typically recommends 30-40 follicular units/cm2 in the very frontal hair line to achieve naturalness at density near to what nature provides—exceeding this may not serve aesthetic goals. For example, higher density can stand out too sharply from surrounding areas and appear unnatural. A hairline should appear like a gentle transition, not a stark wall—the latter are often identifiable as a transplanted hair line. Naturalness requires that density goals mirror nature and not an arbitrary goal density. Behind the frontal hair line, a minimum density recommended for thinning, natural coverage is 20 grafts/cm2—with up to 30-40 grafts/cm2 depending on both short and long term assessed needs. Again, this depends on a patient’s goals usually determined in consultation, risks for future hair loss, and predicted needs to use more donor hair in the future if/as hair loss progresses.
Balancing Today’s Goals with Tomorrow’s Possibilities
The availability of donor hair is a critical factor in determining how to distribute graft density. For example, a patient with 250 cm² of bare scalp would need 10,000 grafts at 40 grafts/cm²—an enormous demand! Calculating graft needs must consider today and next year or the next decade. Donor areas typically measure 30 cm in length and 6–7 cm wide (180–210 cm²), with average occipital donor density ranging from 65–80 follicular units/cm², and slightly lower density on the sides. This translates to roughly 12,000–14,000 total follicular units, and harvesting half this number could thin the donor area noticeably. This usually isn’t necessary to achieve cosmetic goals. A true expert must master the art of making less look like more—strategically concentrating density where it matters most and using lower density in areas where it’s still cosmetically effective. Especially for patients who are uncertain about using medication or who aren’t certain their pattern is stable, a conservative approach is warranted where the grafts will provide permanent coverage, which can be blended with surrounding hairs to augment density and create new, flattering frames and contours while allowing medication response over time to be assessed. This can also modify predicted hair loss.
Planning for Your Future
Predicting future hair loss is complex, especially in younger patients with a family history of advanced hair loss patterns, such as Class 6, even if they currently show only mild thinning and hair line recession (e.g., Class 3). A patient stable on medical therapy may have a good chance of maintaining stability, but others who discontinue treatment could face substantial progressive loss. Even patients in their mid-50s, who had full heads of hair until their late 40s, can develop significant pattern hair loss from androgenetic alopecia (AGA). Dr. Keene’s approach assumes most patients may experience some degree of AGA progression and provides recommended transplant density to be cosmetically appealing while preserving donor hair for future needs.
A Thoughtful, Conservative Strategy
Aggressively harvesting the maximum number of grafts ignores individual factors and risks premature donor depletion, as well as accelerated hair loss in areas affected by AGA. This could leave patients with regret, especially as exciting new treatments, like PP405 (currently in clinical trials), may soon stimulate scalp stem cells to regenerate hair follicles, provided they haven’t been fibrosed—or haven’t already been shocked and lost from aggressive surgery. For now, filling in areas devoid of hair follicles can aesthetically restore a more youthful appearance, and preserving existing hairs with current treatments (both pharmaceutical and non-pharmaceutical) remains a key approach for most patients.
Dr. Keene’s mission is to achieve natural appearing, aesthetically pleasing results with every surgery, but usually with the fewest follicular units possible to achieve a patient’s goals. This ensures a reserve of grafts for future use if /as your hair loss progresses. Aggressive transplantation into mildly thinning areas, as previously noted, can also increase the risk for “shock loss” (telogen effluvium) or accelerate AGA, whereas a conservative approach, combined with medical therapy, may preserve those hairs.
Personalized Care for Optimal Results
When medication stabilizes your hair loss pattern and family history of hair loss patterns support the use of larger graft numbers to cover larger hair loss areas without compromising donor density, Dr. Keene may recommend a bolder approach—at times transplanting over 6000 grafts in a 2 day surgery session combining both FUT and FUE to maximize graft numbers. Again, surgical techniques that preserve residual donor density (that is the density of the donor area AFTER surgery) are used, mindful that patients may require additional grafts in the future. However, if there’s a substantial risk of accelerated hair loss based on current coverage or predicted imminent progression, or the area is smaller and surrounding hairs will effectively block light making it appear more dense, a more conservative graft number may be advised. Patients with hair characteristics like curls, low hair/scalp color contrast, or strong caliber can often achieve excellent results with lower graft density, making conservative plans even more effective and desirable.
It’s far easier to enhance an area later for styling ease than to restore donor density after aggressive surgery leaves little to work with. While beard and body hair are donor options for some, their quality is often less ideal, making careful use of scalp hair a long-term priority.
Dr. Keene is committed to creating natural, lasting results to enhance personal confidence while helping patients plan wisely for the future.
