September 7, 2018 Patients that come to me for hair revision all have the same story: their first- and sometimes second- procedure didn’t work. They ask if I can tell how many of their grafts remain in their scalp, and my first response is “how many grafts did your surgeon harvest and how did your surgeon prepare your grafts?” The second portion of my question is the all-telling answer to my patients. Hair transplant facilities will market 1,000 grafts for an unbelievable price, but sometimes the prized result doesn’t follow. It is important to know that a quote for 1,000 grafts does not always equal 1,000 grafts, it varies by tremendously by the procedural approach. One process, that I’ve rarely see anymore, is hand counting. Some teams will use a hand counter when harvesting via Follicular Unit Extraction (FUE). When harvesting these grafts it is often difficult to ensure that enough “viable” hair grafts have been extracted. The naked eye cannot see which hairs are in ‘growth phase’ versus their ‘resting phase’. Another process, is microscopic counting. When the grafts are viewed under a microscope, technicians will oftentimes “trim and split” the grafts. This trimming of excess tissues around the graft allows for optimal implantation. However, it is very important to not split grafts! The ‘Splitting Method’ is when the team harvests larger ‘chunked’ grafts and splits the hair follicles within the grafts to a few individual grafts. This is the key marketing strategy for inflating a patient’s graft numbers. By this procedural approach, a team can technically harvest only 250 grafts and split them into 1000 grafts. The ethical issue with splitting is that patients are subjected to being charged 4 times the price, even though their surgeon didn’t actually extract 1,000 grafts! Which brings me back to my redundant point; the naked eye- even under a microscope- cannot see which hairs are viable for implantation. And if you are splitting a clustered graft into a few smaller grafts, you could be at risk of taking more ‘resting-phased hairs’ from the same cluster. Lastly, my procedure of choice is ‘Software Counting.’ This method is the most accurate method of grafting because each graft is automatically counted. The ARTAS system has software that not only counts the grafts, but also only selects ‘viable’ grafts to harvest. Yes, it selects ‘viable’ grafts! This can be helpful for patients who want some means of verification that their extracted grafts are ethically counted as well as upholding to their quality. In my office, we always extract a slightly higher number of grafts to account for the small chance that some grafts were transected by the robot. Transected Hair from Manual Follicular Unit Extraction (FUE)Transection is the unintended splicing of the hairs from the full graft, leaving them unworkable for implantation. Transection rates are extremely low with ARTAS, but increases with handheld FUE grafts.I like to remind my hair revision patients that it’s the quality of procedural approach that determines how many grafts you can harvest for your scalp, and the ‘bang for your buck’ deal does not always apply with hair restoration. My advice to patients that are consulting with surgeons for hair restoration is to be sure to question the approach with the quote, and remember that “1,000 grafts does not always equal 1,000 grafts”.