Hair transplantation with Dense Packing for women and men

Andreas Krämer Hair4life



Hair loss sufferer, consultant since 2004, co-author of the book “Hair Transplantation Guidebook” by Alliance4Hair, founder of Propatient with lawyer Chr. Bomke, co-founder of the HTTC training center for doctors. Known from SWR, SAT 1, ZDF, Spiegel and many others. About Us

Achieve the densest possible hairline with a hair transplant!

Hair transplantation with Dense Packing in women: A transplanted women’s hairline with dense packing of 55 grafts per sq cm
Dense packing hair transplant in men: A transplanted male hairline with dense packing and approx. 65 grafts/FU’s per qcm

The term “Dense Packing” describes one of the different possibilities for women and men in the field of hair restoration surgery. It refers to a method of application in the recipient area for women and men, in which a comparatively considerably higher number of grafts/follicular units are implanted on one square cm of scalp than is practised in the usual operations.

Hair transplant Dense Packing is not a commonly accepted and practiced method

Today’s modern options for hair transplantation allow for different procedures. The possibility of Hair transplant Dense Packing in the recipient area is discussed quite controversially and is not considered effective and advisable by every hair expert. This is due to a number of factors, including the fact that “dense packing” requires experience and enormous skills on the part of the surgeon, as well as considerably more time, and also involves more risks than a hair transplant, in which only lower densities per square cm are transplanted.

Some basics and information on Dense Packing for a better understanding

Based on the latest background information, it is assumed that follicular units (FUs) in their natural state have a density of 75-100 FUs per square cm. These FUs, also called hair bundles, have between about 1-4 hair follicle each.

The naturally grown density is not basically equal, in the area of the temple points, for example, the density is usually somewhat lower, whereas in the area of the back middle hair wreath it is usually somewhat higher with about 80, 90 or even 100 FUs per sq. cm. This is what naturally grown hair looks like on average in humans.

Lateral view of the temples and donor area above the ears

Measured density in the area of the temple points and in the lateral hairline area: 50 FU`s per sq. cm

View from the back

Measured density in the back: 83 FU`s per qcm

However, if hair is transplanted into the scalp, the ratios are completely different! In the end, it must be clear to everyone that hair restoration surgery is merely a redistribution of hair and offers only limited possibilities, as well as the full hair as at 18 can never be achieved again. However, it is assumed that often transplanted densities of about 50% of the original density are sufficient to achieve a good optical density and in the literature on hair transplant one can find information that already describes densities of more than 35-40 FUs (Follicular Units) per square cm as “Dense Packing”.

What does “Dense Packing” mean in detail?

As already described, “Dense Packing” is currently the most current and also the only hair transplantation treatment technique to achieve an enormous hair density per square cm, which differs significantly from other, well-known hair transplantation procedures.

Immediately after the surgery: 60 grafts/FU`s per qcm were transplanted with Dense Packing
Immediately after the hair restoration surgery with dense packing: 70 grafts/FU`s per qcm were transplanted

If Dense Packing is used, significantly more FUs (follicular units) are transplanted on one qcm, thus more openings (recipient sites) are required in the scalp and these are also quite close together, which makes the subsequent insertion of the follicular units considerably more delicate. With this measure, a very high density can be achieved, but only if both the treatment itself and the patient’s postoperative course are without any undesirable incidents. What can prove to be very unfavourable and what risks there are with a hair transplant with Dense Packing, you can read in the following paragraph under “Risks and important information about hair transplantation with Dense Packing”.

Risks and important information about transplantation with Dense Packing

In addition to the well-known general “hair transplant risks” that must be taken into account, there are also special circumstances with “Dense Packing”. One man’s joy is another man’s sorrow, that’s what you could call it at first, because many patients are not sufficiently aware of the special risks they take when having a hair transplant with Dense Packing. Others, on the other hand, are aware of all possible eventualities and still accept that events can occur that significantly and negatively influence the result of Dense Packing.

At this point, it is up to the doctors and clinics to provide comprehensive information before a hair transplant in such a way that all the risks, but also alternative options, are explained and made clear to patients who are too euphoric.

Loss of transplanted grafts due to lack of blood supply

This risk is not insignificant, because if this should happen, several of the hair units (follicular units/FUs) that have just been transplanted will be irretrievably lost after the hair transplant. It is hardly possible to influence what happens, because whether such a situation will occur depends on the systemic processes of each patient – quite individually. During the transplantation, an optimal scalp blood supply provides the hair roots with the “nutrients” that are needed for healthy hair growth. However, if there are considerably more hairs/hair roots per square cm to be supplied due to the dense packing, there may be a lack of supply due to insufficient blood circulation, which may result in the loss of some or even several follicular units (FUs)

Risk of low growth rate

The already mentioned possible lack of blood supply to the scalp during hair transplantation can result in the loss of grafts (FUs/follicular units). This inevitably results in a much lower growth rate than originally envisaged

Loss of donor grafts, fewer FUs remain for later procedures

For the treatment method “hair transplant with Dense Packing”, a larger number of donor grafts (follicular units, obtained from the donor area) must be used than with other hair transplantation procedures. If the patient loses several of the newly transplanted grafts/follicular units (FUs), for example due to insufficient blood circulation, the already significantly higher number of donor grafts is lost and there are significantly fewer donor grafts available for follow-up care or even later hair transplants on other parts of the head.

Possible mistakes during a hair transplant with Dense Packing

During a hair transplant with Dense Packing, there are some risks, because the Dense Packing treatment method requires skills from the performing doctor that require special knowledge. Even with a great deal of experience and know-how, it cannot be completely ruled out that this extremely delicate work will be successful in every case. Thus, despite the greatest possible skill, it can happen that negative circumstances occur, because:

  • The insertion openings with Dense Packing and the densities to be transplanted of > 50/55/60 FU`s/grafts per sq cm are considerably smaller than if only conservative densities are to be transplanted, such as a density to be transplanted of 25-30 grafts per sq cm. In addition, the openings in dense packing must be placed very close together in order to achieve the intended density. This requires absolute precision work that can be both physically demanding and extremely stressful on the eyes
  • The doctor’s eyesight can deteriorate during the transplantation due to the enormous effort. In many cases, magnifying glasses are used, but there is still strain, especially with regard to this extremely delicate work under the focused light of the spotlights that illuminate the surgical field
  • The follicular units (grafts, FUs) can be damaged. With the already tiny distances between the small insertion openings, it must be possible to transplant the FUs into the openings undamaged and intact. Bumping into skin edges or instruments can damage the hair units, so full concentration and absolute precision are required here as well
  • The “Dense Packing Procedure” can only be performed very slowly due to the highly concentrated, filigree precision work. Under certain circumstances, this can take many hours and, if necessary, strain both the doctor and the patient and, in the worst case, negatively affect them

Achieving a holistically successful treatment goal with an hair restoration surgery and taking into account different expectations

Here, some factors should be clarified in detail so that patient wishes and ideas in interaction with the medical advice/treatment plan result in a unanimously coordinated approach.

In the analysis of years of experience, it has become apparent that very young patients usually want to achieve a high hair density at all costs with only one procedure, whereas some older persons (e.g. men around 60 years of age) would rather be provided with a somewhat lower hair density in order to achieve a consistently natural, age-appropriate result. Men at a very young age and men who are in the middle of life usually have a different demand on the presentation of their own person than, for example, men at a mature age.

Example of a conventionally transplanted density compared to a transplanted density with Dense Packing

Own hair transplant density comparison: 35 grafts per sq cm vs 60 grafts per sq cm

The picture on the left shows the fitness couch Alexander Gaier – known from the SWR hair transplantation report Schlaglicht – after his first receding hairline transplantation and before the FUE hair transplant with Dr. Lars Heitmann and with a measured density of approx. 35 grafts/FU`s per qcm – and on the right the result of another patient of Dr. Heitmann with a transplanted density of approx. 60 grafts/FU`s per qcm.

As can be seen in the above example, a transplanted hair density of 60 grafts/cm² has a much better optical effect than a density of 35 grafts/cm² (with similar hair characteristics). However, how “full” or how “dense” a density per sq cm looks visually also depends considerably on the characteristics of the transplanted donor hair, which factors we discuss below.

In this example, it remains to be said that later satisfaction is strongly dependent on expectations. Patients of older age would most likely be satisfied with a 35 density per square cm, but men of younger age like Alexander Gaier would not. The exact expectations of the patient and whether these can be achieved with the planned hair transplant with the respective technique and clinic philosophy should definitely be discussed in detail with the patient before the procedure.

With hair transplants, the optical effect of a transplanted density depends on many factors

It is important to remember that “how” a certain number of grafts will look later depends on many different factors, such as hair thickness, hair structure, hair colour and whether there is a low or high scalp hair contrast. With low scalp hair contrast, transplanted densities often look visually much denser.

When Dense Packing is not required for hair transplantation and lower densities will result in satisfaction

In cases such as when there is low scalp-hair contrast (light scalp to light hair, or dark scalp to dark hair) and the patient has thick hair, as well as curly hair, then only mildly placed densities per square cm may be sufficient.

Hair transplant example density 30 grafts/Fu`s per qcm

The picture above shows a hair transplant result by > Dr. Mwamba from Brussels with a transplanted density of around 30 grafts per qcm. In this case, an optically sufficient effect was achieved with a rather mild planting per qcm. However, the following factors are present here:

  • Low scalp-hair contrast
  • Thick hair calibre
  • Curly – frizzy hair

A hair restoration and the wish for dense packing – high hair density and higher demands on the hair surgeon

The desire for lower hair density does not place additional demands on the hair surgeon, but the ideas of very high density do (in principle, it can be stated: The lower the density, the faster and technically easier the procedure). In this case, the “Dense Packing” method is currently the most modern way of achieving this, although this also results in the hurdles of implementation, as only a few of the renowned hair surgeons have specialised in this field to date.

Information on Dense Packing for women in particular

Basically, in the case of hair loss in a woman or in women, it must first be clarified whether it is really the classic hereditary hair loss. If there is no diffuse hair loss, circular hair loss or hair loss caused by medication or pregnancy and the hairline or donor area is well preserved, women can also have their own hair transplanted (see hair transplantation in women). The advantage for women is that hair loss does not usually lead to a full bald head and therefore higher densities can be set during hair transplantation and dense packing can be used more intensively.

Dense packing in hair transplantation: Summary

The “Dense Packing” method can produce very appealing, dense results in the positive interaction of all factors, although the risks increase. For this, some criteria must be fulfilled in the best possible way: The doctor should have ample experience, a broad band of know-how and the patient should be suitable in terms of a holistic approach to the individual case. A few renowned hair surgeons with excellent knowledge have specialised in these procedures and can prove first-class results. Nevertheless, the use of dense packing in hair transplantation is associated with risks and even if the risks can be reduced, the risks cannot be completely eliminated. Equally excellent hair surgeons deliberately do not perform “Dense Packing” because they do not want to bear the additional demands and risks, as the proportionality in terms of success has not been fully convincing so far.

If, for example, the patient is rather young and, due to his or her family history, it is foreseeable that the existing AGA (androgenetic alopecia, hereditary hair loss) will still progress drastically, then special care is required. If the patient is already unable to accept living with a visibly thinned-out hair status, then everything should be done with foresight to keep the consumption of the existing hair units in the donor area as low as possible so that further hair transplants can still be made possible in later years. Consequently, methods with additional consumption + increased risks should again be particularly examined, so that the patient perhaps changes his mind and takes the path of lower risk by achieving the intended result in several steps by means of common natural hair transplantation procedures.