The Benefits of Direct Hair Implantation
The following is a transcript of Episode 9 of the Hair Restoration With Dr. Daniel A. Danyo podcast.
Dr. Danyo: If you’re the type of patient that wants ultimate control or have somebody who is in charge of the procedure have ultimate control, then direct hair implantation is what you should be searching out.
Clark: That was the voice of Daniel A. Danyo MD, founder and physician at North Atlanta Hair Restoration, a boutique medical practice solely dedicated to the diagnosis and treatment of male and female hair loss. You’re listening to Hair Restoration with Dr. Daniel A. Danyo. I’m your host Clark and all season long we will speak with Dr. Danyo about how he and his team at North Atlanta Hair Restoration are helping his patients transform their everyday lives for the better. In this episode, Dr. Danyo discusses direct hair implantation, the process of placing grafts using a specialized pen shaped tool, which allows Dr. Danyo to deliver incredible results for his patients. We’ll cover the advantages of doing DHI, and how Dr. Danyo and his team at the North Atlanta Hair Restoration have perfected the technique. There’s so much to talk about. So let’s dive in.
Dr. Danyo, it’s great to be back here on the line with you. I always love our conversations.
Dr. Danyo: Likewise. How are you doing Clark?
Clark: I’m doing well. I’m doing well. I’ve got… It’s been a good time as much as it can be right now. I know these are different times we’re in right now. But trying to stay optimistic and trying to stay positive and conversations like these with you help me feel better and and learn more and continue learning. So I’m excited to dig into this topic. So we’ve talked often about FUE as a style, as a procedure type, I’ve been learning so much about all of this with hair transplantation and talking about all the different options that are out there, the differences that you offer compared to other folks. So we’re gonna continue learning about FUE, but on this case, it’s gonna be on the placement side. So I know this is a lot of like…for someone who’s new to this, and they’re learning just like me, could you from a high view, you know, zoomed out perspective, could you just explain really briefly what FUE means, what that is, and then we’re gonna start talking a little about today’s topic.
Dr. Danyo: Which is direct hair implantation. So FUE is basically a form of extraction of the grafts, where we take random hair follicle groupings with a small punch which is generally either just below a millimeter or at 1-millimeter which the punch is circular so it makes a circular incision around the graft. And if you get deep enough, you can then loosen the follicle where it can be pulled. And then those grafts are then stored to be implanted. So, we’ve talked about how we extract, and I think we do things a little bit differently because I’m a physician, I do all the extractions with the device. My technicians do a really safe double-handed technique to pull the grafts. We have a great storing mediums, called HypoThermosol with ATP, which are similar to if you’re getting a kidney or a heart transplant, so that the grafts are really hardy in this solution out of the body. And then once we get all the grafts, then we go to what is called direct hair implantation.
Clark: Wow, okay, so what this looks like, I know this is audio only, but let’s say this is a procedure on top of someone’s head. So there’s a section that there’s no longer hair, but they still do have some hair in other parts on top of their head. So basically what you’re describing is taking some where there’s a lot and putting it where there’s none.
Dr. Danyo: Correct and we call that the recipient or graft area. So what direct hair implantation is, is that we are using a device called an implanter pen to do a stick and place technique where we load the graft into the implanter pen. I grab the implanter and then I literally inject it or stick it right into the head at the right angle, the right curl in the right depth, which is different than what’s generally done in most practices where the physician will do surgical slits using a small scalpel blade or even a needle to create an entrance wound, for the grafts that are then hand placed. And today, we’re just gonna talk about the vast advantages of doing direct hair implantation and why I’ve done this solely for the last eight years. And in fact, I’m approaching placing almost 2 million grafts.
Clark: Two million?
Dr. Danyo: Almost 2 million. And so…
Clark: Because you’re doing this…and the significance of that number is that these are individually…it’s like planting trees, I guess.
Dr. Danyo: Yes.
Clark: You have a huge acre or whatever. And literally you’re taking one tree out and you’re relocating that tree to be healthy and all that.
Dr. Danyo: Yes.
Clark: But you do that each tree at a time or each individual hair at a time.
Dr. Danyo: Well, it can be a single follicle or it can be a follicle grouping of two, three, or four hairs. But they’re done individually. And since I’ve been involved with every graft on every patient in really dealing with all different skin types, a lot of these grafts, especially if they’re multiple, have a lot of splay. So that means like, some of the bulbs are going to the right, and some to the left or, some down, and splayed grafts are extremely hard to effectively place into a small slit where all the follicles are nice and straight and in the right plane. And then lastly, you know, different skin types can be tough and especially curly hair can be extremely difficult to place with manual techniques versus direct hair implantation.
Clark: So someone who’s listening along with us, maybe they’re thinking about this either for themselves or a loved one and we wanna kind of go through and I know we’re gonna get into some of the details, we’re gonna get really close to some of the specifics, but what are some of the things that someone needs to be thinking about if they’re looking at all right, I think A, I know I wanna do this and B, maybe you wanna approach doing it this way as opposed to that other approach that you said other offices are doing which is using a needle or like slicing. That sounds either painful or that’s gonna leave scars. There’s a lot of problems it sounds like with that.
Dr. Danyo: Well, there aren’t necessarily scores. I mean, you have to create an entry wound and the pen implanters have a needle to enter the graft into the skin. But I think as far as the patients go, I think they have to think about what their needs are and who they are as a person. If you’re the type of person that likes to be in control of fine details, who obviously is looking at this as a big investment and wants to maximize results, then I think a direct hair implantation is something that you should be searching out. Because the other route really takes a physician out of the most important part of the procedure which is placing. Because, sure they’re doing surgical slits, but hand implantation is extremely hard. Even occasionally, I’ll do some hand implantation. And I still have difficulty with it, even though I’ve been doing hair transplant since 2012, and it requires very skilled technicians to properly place grafts and a lot of times that’s not the case. There maybe technicians that come and go, or there may be a new technician. I’ve had people that have had really good hair growth on one side but poor growth on the other side and patients have said, the technician on the good side was really moving along and the other one seemed like they were struggling. So that’s…
Clark: So that’s gonna look different.
Dr. Danyo: Yeah, so…
Clark: It’s like someone sewing a shirt or maybe a sweater, two different people on different sides and one’s better and ones not. I feel like that’s gonna look different.
Dr. Danyo: Yeah. So, for me, I have a very strong sense of obsessive compulsive disorder when I do these procedures. And the obsession comes with perfection. And each graft needs to be placed at the right angle, the right curve, the right depth, and then controlling for bleeding, which then ultimately makes the recovery so much faster with less swelling in the face or chance for swelling in the face and really early growth. A lot of my patients say, “Oh, I didn’t get growth from my prior hair transplant till about 8 to 12 months.” I generally see 75% growth on the vast majority, probably 90% of my patients at six months. And in fact my six month I call it high fives and hugs. People come into the office, you can hear the girls up front saying, “Oh my gosh, look at you.” And the patient is just beaming because there’s really good growth. And I’m very sure that direct hair implantation has a lot to do with it as well as getting optimal growth, handling the grafts properly, storing them properly, using minimal amounts of numbing medication and just every aspect has to be perfected to deliver a seamless result both immediately and long term.
Clark: Definitely sounds like there’s that close attention to detail. And you were saying how you can get sometimes obsessive around it. But there’s this phrase, I feel like that came to mind as you’re describing some of this, randomly organized.
Dr. Danyo: Yes.
Clark: So can you tell me more about that?
Dr. Danyo: Sure. When you’re doing surgical slits, your brain wants to organize everything. And I have done surgical slits in the past and I just find that the slits end up being a little bit too organized almost like a number of five dice, you know, where they’re just kind of stacked up, or too linear, and pen implanters allow me to place randomly, but in an organized fashion and that’s what nature is, it’s randomized organization and that also gives, I think, a better look.
Clark: Right. And that doesn’t happen by accident, you have to be intentionally not being in a line or making it look like it was mechanically some sort of factory. You know, that stuff does not look natural and you’re going to make this look as concealed and as natural as possible.
Dr. Danyo: Yes. And again, having done hair transplant on people that have previously had hair transplant and I look at the way the hairs were put in, it almost looks like Arlington National Cemetery. I mean, everything is lined up so perfectly. And especially when I have my high definition loops, which and that’s how I placed the grafts under high magnification…
Clark: High definition loops?
Dr. Danyo: Which are glasses that are magnified. So it’s…
Clark: That’s what you’re wearing as you do this.
Dr. Danyo: That’s what I’m wearing, and you need that fine detail to be able to do it. A lot of people can’t wear high definition loop magnification because you’re almost looking through a small circle about the size of a quarter. And then you have to go into that world out of that world to grab the implanter pen and back into it. At first it can create a lot of nausea, almost dizziness, and…
Clark: Oh, because you’re going super… I mean, that magnification is, I mean, you can see the hair on someone, like an individual hair follicle on someone’s head.
Dr. Danyo: Yes, yes. And especially when somebody has hair present and you’re kind of filling in, direct hair implantation is the best way. I mean, the hair’s protected and [inaudible 00:13:46] I can go in at the same angle without damaging other hairs. And it just creates a very fast and easy technique instead of placing slits in between existing hair and then trying to find those slits. It can be a lot more time consuming. And really with direct hair implantation, if everything is going well and sometimes cases are tougher than others because you can get what’s called popping where you put one graft in and another one pops out. And that’s related a lot to the size of the graft, is it larger at the top and smaller at the bottom, almost like an ice cream cone. Is the skin really tough and elastic? But most of the time, we don’t get popping. And again, there’s no bleeding as we place because we have excellent depth control. And I have placed over a thousand an hour frequently on patients. So the implantation is extremely fast and my assistants are excellent at quickly loading these implanter pens, we usually have between 5 and even up to 10 pen sometimes if it’s a large case, they’re all pre-loaded, I grab one, throw it down, they’re loading it. So I have a constant supply of loaded pens. And we just literally it’s everyone says, “Man, you guys are the machine,” you know, back there…
Clark: You are a machine.
Dr. Danyo: Yeah.
Clark: Because that is a lot to cover. And that’s a long time for someone to be sitting. Are they sitting or are they laying down?
Dr. Danyo: During the implantation they’re sitting. If we’re going from about the two-thirds front of the crown and then forward, the back of the crown because the hairs are kind of spiraled down sometimes, and to the side, sometimes I’ll have people on their side or face down because that’s the best way to place angulation wise, you wanna mimic the swirl of the crown, but otherwise people are sitting up.
Clark: Okay. And you say you can do around a thousand… What’s the word of 1000 per hour? What is that?
Dr. Danyo: Implantations.
Dr. Danyo: Yeah.
Clark: Okay, so what would you say is around the average of how many implantation’s someone needs? And the reason I ask that is that can kind of give us an indication maybe of how long someone has to be sitting there and going through the procedure. Because that really matters, you doing a thousand per hour, that’s gonna really save the time on someone doing this.
Dr. Danyo: Well, it’s saves an entire step. So let’s say you’re doing 2000 grafts. I have placed 2000 grafts in a little over 2 hours. Now, if you’re doing 2000 slits, that takes at least an hour, maybe an hour and 15 minutes to an hour and a half to do. Then, the technicians have to come in and place those grafts. And most technicians can place between 300, maybe up to 500 an hour, individually. And sometimes there are two people placing. But again, you have to have two expert places to do this. But it’s difficult when you have two people placing and the head is moving and a lot of times it’s just one person individually hand placing those grafts. So you’re adding, an hour to an hour and a half just to do the slits, then you have to come back and place. I’m just going right from the start. Once we get the grafts out, we’re placing and since we’re doing it even faster than what two people can do, eliminating the time of the slit formation. My patients, generally I can do 2000 grafts, start at 7:00 in the morning and end at like 2:30 or 3:00 in the afternoon and that’s with taking lunch and breaks. And we’ve just gotten extremely fast. And once you start getting into 4:00, 5:00 you start losing anesthesia, there’s more discomfort. So there’s really a need for one to get the grafts in as soon as possible. And two to not kind of push that timeframe to where people are sitting and their back is sore, and you’re having to reapply anesthesia, which causes more swelling, more discomfort. And so if we can really get these in quickly within that window, then it just makes the whole experience so much better.
Clark: I love it. This is all really helpful. So when you were talking earlier about the depth control, and when you’re able to do that, that is gonna minimize some of the things that might happen like bleeding or something like that. But when you’re able to have that depth control and being able to control what you’re doing, what other benefits come from this?
Dr. Danyo: So, what I do as far as depth control, which is vital, under yeah, using my loop magnification, I put a graft next to the needle in portion of the implanter pen. And then I can adjust the length of the needle so that the graft when it’s placed, the bulb is right at the tip. And then basically I can inject freely to the hub of the implanter pen which it gives me a depth control without going too deep. And it’s vital not to go too deep because once you penetrate the dermis, that’s where the main blood vessels are, even nerves. And most of my patients have minimal numbing in the head. I’ve had people that have had permanent numbness in the head following slits because they were placed too deep.
Clark: Oh my goodness.
Dr. Danyo: Where a nerve was cut. Although that’s…
Clark: That’s terrifying.
Dr. Danyo: Yeah, although that’s rare.
Clark: It is rare, okay. That’s good.
Dr. Danyo: And sometimes people get some temporary numbness for a couple weeks. But depth control minimizes that risk and minimizing the bleeding also minimizes any chance for popping and gives really the best depth control because depth control is vital. I’ve seen a lot of hair transplants where the person who did the slits made them too deep. And when they were hand placed, the hair actually sunk below the skin level and people have permanent pitting in the skin, which looks terrible. And so it’s like having the hair in a little indentation. And so depth control is vital to really put the follicles so that it grows right at the right level. The other thing is you don’t wanna place too shallow because then the top of the graft will dry out and then the yield will be low. So we do really precise depth control and you can change literally even .05 millimeters. It…
Clark: How small is that?
Dr. Danyo: It’s small. And that fraction of depth control can change the amount of popping and bleeding and literally just make these really fine tuning changes on every implanter pen that we use that’s tailored to the patient so that we can just do these things really fast, have really good results. The other thing, we talk about depth control but the pens have so many advantages compared to hand placing. The next is gonna be angulation. A lot of times I do a shaveless procedure where people have existing hair. And when I have my loops on, I see the exact angulation of the hair. And I can place those grafts at the exact angle as I’m going each time. So that’s important. I can lay them down, say if I’m doing implantation on an eyebrow, you want those hairs almost horizontal to the skin, you don’t want them sticking out. And the last aspect is gonna be curl control. Every hair actually has a curl. And when you graft hair from the back, all those hairs are actually curling down. And since we’re coming at an angle the graft has a slight angulation to it. And the bottom part of that angle is where the curve is going down. So as I’m doing this under loop magnification, I either turn to the right or to the left to angle it up or down. So all the hairs are not only at the right angle, but they’re also at the correct curve, which also greatly improves how the graft sits in there and how it grows. You don’t want hair kind of curling up and some curling down.
Clark: It’s like a permanent cowlick or something like that. It’s sort of…
Dr. Danyo: Exactly.
Clark: In a way, it’s how I’m seeing what you’re describing.
Dr. Danyo: Yes, but these are all fine details that literally have taken me years to perfect and be able to do this quickly. It takes a lot of concentration and energy to do it. But, again, it’s kind of like an athlete that is just trained to a high level and become proficient at something that seems impossible or difficult to do, not impossible. But that’s where that OCD comes into play.
And then the final thing which is so critical, is you want the texture of your hair and the length of the hair to be straight. And when I say texture, if the…back to the surgical slits and hand placing, if the hand placing is not done correctly, you can almost get a curl in the bottom of the graft. And that’s because you’re taking a graft and stuffing it through a pre-made hole. And you remember the Grinch that stole Christmas, you remember when he got stuck in the chimney.
Dr. Danyo: How he was bent kind of upside down like that. So hand placing has a very high chance of having not all but some and if it’s placed poorly, even the majority of hair that has the bulb that is above the hair, the graft is not placed in an elongated fashion. And if that happens, that hair will be permanently kinky and it will have a very strange texture almost like beard hair, how it just kind of curves and just, it’s not straight and [inaudible 00:25:26]. And that is a critical feature. Again, back to having done a lot of cases on people that have had prior hair transplants. I’ve seen people that have had just poorly placed grafts with lots of kinky hair. It just looks terrible. They can’t wear it long. They have to wear it short or they have to put product in to make it cooperate. And to them it’s extremely frustrating.
Clark: Well, I appreciate you sharing your insights into all of this and I know they’re so many details. I know you use the word obsessive on how you can get so dialed in to this kind of work, but it all is for the patient and I know you are the person who actually does all this. It’s not something that gets tasked to someone else. And there’s a lot of pride in that. So, I appreciate you jumping in to this, talking really closely on all of the details…
Dr. Danyo: I have one other thing I wanted to bring up.
Clark: Oh, yeah, please.
Dr. Danyo: There aren’t a lot of facilities actually offering direct hair implantation. And I think it’s because of everything I talked about. And really the difficulty of transforming your practice for one because if you have experienced techs doing hair transplant…I mean hair implantation, with following the slits, and then you say, “We’re gonna change that to hair implantation,” it creates a revolt in your office. Because now you’re taking experienced techs, and then you’re training them how to do loading the pens, which actually is very quick learning. It’s not a difficult task. And it takes kind of their expertise out of the mark. And it just takes years to get proficient and fast and do this at a detail that we described with the depth control, curl control, and angulation, proficiently. So that is why most offices don’t offer it.
Clark: Good to know. Well, Dr. Danyo, as always, thank you so much. What’s a good way for someone to connect directly with you and your team?
Dr. Danyo: Sure. We have multiple ways to connect on our website. With the COVID-19 pandemic going on, we’re doing a lot of online consults, and we’ve made it extremely easy where we have a texting app that we don’t use for any social media or any mailings or things like that. It’s only…
Clark: Like, if you text it you’re not gonna get put on a list.
Dr. Danyo: No, no. And it’s only for communication. But we can do video chats, which are HIPAA compliant through Klara. And that’s K-L-A-R-A. People can just send pictures of their head. And we then communicate, can do either phone or video and do online consults. Another is to just call the office. We are doing some in-office consultations for local people. It’s not required. And those have to be scheduled out. We’re trying to schedule them at a time when nobody else is in the office. But I would say 90% of my patients that…new patients that I’m doing hair transplant on, I am meeting them the morning of the procedure. We’ve already discussed everything, either through video chat or phone, I’ve looked at the pictures, we’ve come up with a game plan, I’ll generally do a range of grafting from, say 1500 to 2000 to give some leeway, I will do an in depth evaluation the morning of and say, “You know what? You don’t need 2000, let’s just stick with 1500,” or vice versa. And the other thing is it sets up a line of communication through texting. Which is nice because I generally have about six to eight conversations a day with people, whether they’re new patients or old patients, and we use that format with preoperative instructions, post-operative instructions, we send videos, all the information is through there. So it’s just a great way to communicate and I think extremely modern and accessible and just easy because texting is an easy way to communicate.
Clark: Very nice. It is an easy way. And I know we’ll plug that number here in the outro again and also the blog post where this is that and all that good stuff.
Dr. Danyo: And our phone number is 678-845-7521 and the website is www.nahairrestoration.com.
Clark: Wonderful. Thank you and I’m looking forward to our next conversation.
Dr. Danyo: Likewise, take care.
Clark: Thanks for listening to Hair Restoration with Dr. Daniel A. Danyo. You can book your consultation today with Dr. Danyo by simply calling 678-845-7521 or online at nahairrestoration.com and be sure to subscribe, rate and review this podcast wherever you listen to your audio content.
Dr. Daniel A. Danyo is the founder and medical director of North Atlanta Hair Restoration, specializing in treating hair loss in both men and women. He is one of only 300 people in the world certified by the American Board of Hair Restoration Surgery.
He is a member of the American Board of Hair Restoration Surgery, International Alliance of Hair Restoration Surgeons, American Hair Loss Association, and The International Society of Hair Restoration Surgery.
He is also an early adopter and pioneer of Shave-less FUE, one of the most discreet surgical procedures available for hair restoration. Dr. Danyo performs every procedure himself, from start to finish. He individually extracts and places every graft on every patient. Learn more about Dr. Danyo on his Meet Dr. Danyo page.