The Complexity of African American Hair Transplants
The following is a transcript of Episode 20 of the Hair Restoration With Dr. Daniel A. Danyo podcast. In this episode, Dr. Danyo explains the difference in hair restoration procedures for African Americans. He also shares about what motivates him as he works in the industry and how he navigates conflicting work ethics and philosophies.
Dr. Danyo: The key is that a lot of physicians or a lot of offices that provide hair transplants don’t feel comfortable doing African-style hair because of the curl and because of the coarseness of the hair. And the problem is on the grafting side because you’re using a punch that constrains the graft. If you’re not careful and you don’t have the right touch and the right equipment, you can cut through that curve and that curve then gets cut or the graft gets cut through the curve and then it could potentially not be viable or not a great graft to move.
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. And you’re listening to “Hair Restoration with Dr. Daniel A. Danyo.” I’m your host, Clark. And all season long, we’re speaking 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 explains the difference in hair restoration procedures for African Americans. He also shares about what motivates him as he works in the industry and how he navigates conflicting work ethics and philosophies. There’s so much to talk about, so let’s dive right in.
Hello, Dr. Danyo. How are you doing today?
Dr. Danyo: I’m doing great. How are you?
Clark: I’m doing well. I am always happy to be back here on the line with you to chat through some of the things that you’re doing, some of the things you’re working on, some of the perspectives that you have accumulated in the industry, and talk about the passion that you have in hair restoration. You’re bringing a lot of happiness to people. How are things going over there?
Dr. Danyo: Things are going great. We’ve been busy. We’ve had a lot of out-of-town folks, so it seems, especially from California. I don’t know. Maybe the podcasts and outreach and the fact that the most of the case, but we’ve been getting a lot of people from out west and just some really, really great patients, great stories. So, it’s been fun.
Clark: I love that. That is a good point. You do have people from all over, of course, you’re in North Atlanta region area, but people come in from all over. And as I understand, a lot of people will come to Atlanta and they make it into a little staycation of sorts because there’s a lot of cool things to do on a little trip to Atlanta.
Dr. Danyo: Yeah. Alpharetta is a great little town. So, everyone is kind of surprised when they get up here, how nice it is. So, there’s a lot to do. People bring their spouse and the spouse has a good time while we’re doing the case. So…
Clark: Oh, that’s right because it takes a lot of time. This is not like a drive-through here, this is, especially with the way you have this boutique practice set up, you’re going from start to finish with a patient every step of the way, and depending on what you’re specifically doing as far as how many graphs and all that, it can take several hours. So, it is.
Dr. Danyo: Oh, yeah.
Clark. Hey, that spouse is going to have some activities to do while they’re waiting.
Dr. Danyo: Yeah. Some good shopping and all that stuff. So…
Clark: That’s good. Good deal. Well, every episode we’re talking about a different perspective or a different set of questions and common questions that you’re getting. And one of the questions that you’re often getting is, can African Americans get a hair transplant? And there’s a lot of perspectives that you’ve accumulated through this industry, and you do a lot of work with people of all shapes, sizes, and backgrounds. And I wanna talk with you here about this particular type of hair that you have created a reputation of being well sought out, people from all around the country coming to see you.
Dr. Danyo: Yes.
Clark: So, how do you approach this? What’s different? Catch me up to speed here.
Dr. Danyo: Well, first of all, it absolutely works with my African American patients. The key is that a lot of physicians or a lot of offices that provide hair transplants don’t feel comfortable doing African-style hair because of the curl and because of the coarseness of the hair. So, that curl comes out of the skin, but the curl actually goes down through the graph.
So, sometimes it’s like the curl of, like, a J, sometimes it’s a curl of a C, but usually, there’s at least some curl. And the problem is on the grafting side because you’re using a punch that constraints the graft, if you’re not careful and you don’t have the right touch and the right equipment, you can cut through that curve and that curve then gets cut or the graft gets cut through the curve.
And then it could potentially not be viable or not a great graft to move. So, what we’ve done is just practice in seeing about 25 of my patients…25% of my patients are African American just doing repetitive work. We get great grafts similar to my Caucasian and Asian patients. And that’s not an issue as far as doing FUE, which is follicular unit extraction in working on African American patients’ hair. It’s just not an issue for us.
Clark: Right, 25%? That’s a lot of folks. So, for someone who might be new to the podcast, could you just, like, in your own words, you know, 20 seconds here, just a quick background on how many years you’ve been doing this and how you started, and how you’ve really become one of the most sought out people doing hair transplants?
Dr. Danyo: Sure. I started in physical medicine in rehab in pain management and was in private practice for about 12 years, and then abruptly made the switch to hair restoration because of the ethical dilemmas that I faced in that world of pain management. And I wanted to be free from that and do something that now I have a passion for, which is really serving patients.
And hair, when people lose it, it can have a…just a major impact on their sense of well-being and their sense of self. So, I quickly learned that what I was doing was switching to hair was just awesome stuff. And also, I realized that most practices in the country were not doctor-patient focused, they were sales-patient focused. So I’ve kind of taken a different route in being physician-patient-focused and actually doing every grafts extraction wise and placement wise on every patient to where now…I’ve done actually over three million grafts. Yeah. I’ve been…
Clark: Over three million.
Dr. Danyo: Yeah.
Clark: How many… That? Wow.
Dr. Danyo: Yeah.
Clark: And for perspective, that is… How many patients is that if you had to estimate? I’m not putting you on the spot here.
Dr. Danyo: I don’t know the exact number. It’s well over a couple of thousand procedures that I’ve done.
Clark: So, it’s tens and tens of thousands, if not hundreds of thousands of hours.
Dr. Danyo: Well, yeah. It’s a lot of hours. And it’s a lot of tedious time, but while I’m doing the case, I have a mind where…I like to create things and I like to imagine things, so I’m constantly thinking, “How can I do this better?” and also listening to my patients. And one thing we do a lot of is a Shave-less FUE. And if you look at African American females that have traction alopecia, which is almost at an epidemic level where hair transplant is really the only treatment, I had to dig deep to say, “You know what? I’m gonna do a Shave-less FUE procedure for all of my African American female patients because they don’t want their head shaved. And the other thing is they don’t wanna go through a strip procedure where they have a permanent linear scar.”
So, I might be one of the only people in the country doing that for African American females, but it’s a mentality-driven thing where I knew that there was a need and I worked through the kinks with small cases at first and then got bigger, bigger, bigger so that we can do large cases up to a maximum of 1,500 grafts per case, shaveless in a very doable time. It generally takes a little bit longer but might take six or seven hours. It’s not like this massive, complicated procedure that a lot of people in the industry feel that it’s almost impossible to do.
Clark: What’s the hesitation from other practices, and how can we learn from that, and how does that relate to the many people that you’re working with?
Dr. Danyo: The biggest hesitation on the extraction side where you’re actually taking grafts out from the side and back of the head relate to the curl that we talked about earlier. And it can just be really hard. We use an oscillating trumpeted punch, and I feel that that’s the only punch-in mechanism with oscillation not spinning like rotation to get grafts without damaging them.
So, a lot of practices, they only have sharp, rotating punches. That’s the machine they have, that’s the only thing they can do, and those are the only punches that they can use. And that’s a big problem because those sharp punches tend to take more of a straight-line approach for cutting. And if there’s a curl, it’s gonna cut right through the curve. So, the oscillating trumpeted punch, that trumpet cuts at about a 30-degree angle away from the graft. So, you can actually incorporate the curl in that and go very deep on the follicle without transecting it or cutting it.
And the next issue is if you’re just using a sharp punch, they maybe won’t go as deep because you’re getting transections, but then it can be very difficult to pull and you can injure the graft that way. So, it’s very important to have a clean-cut and a deeper cut to go through the attachments where you get intact grafts, where you’re not cutting through the extraction side. And when you pull the grafts, you’re not creating a lot of tension and injuring it that way.
So, the vast majority of our grafts are, I mean, they’re equivalent to my Caucasian patients where the transection rate typically is 1% possibly 2%, and sometimes no transections. You don’t want to be in a situation where you’ve got 20% or 30% transections just because the hair is curly. That’s a bad situation. And then the next issue relates to just placing the grafts. Most places will do surgical slits first because you have to create an entrance for the graft to enter in the head.
Clark: You’ve talked about this way to think about, it’s almost like you’re lifting a tree up…
Dr. Danyo: Yes.
Clark: …and then replanting that tree somewhere else.
Dr. Danyo: Yeah. So, if you’re doing surgical slits and then placing them with forceps, which are basically glorified tweezers, it’s very hard to make a curve go into a straight hole. So, placing can be an issue. In a lot of places, just find the difficulty is with extraction and placing, honestly, they say, “We just don’t… We can’t service you, and we’re sorry. You’re gonna have to find a provider to go elsewhere.” We use implanter pens.
So, the nice thing about the implanter pens is the graft is loaded into the pen, and then it’s basically stuck… It’s a stick-in-place maneuver, we don’t do any surgical slip. And what we do is we take that curl and the curl always comes out, which is great because then I can use that curl to put it in the right trajectory. And it’s easy to place. So, we can place quickly with minimal trauma. And again, it’s just not an issue for us with our technique. And I would say most places don’t use pen implanters because most doctors are not placing the grafts and technicians are not going to use implanter pens to place.
Clark: And a whole nother conversation that we’ve talked about before, sometimes it’s not even the doctor, sometimes it’s a technician that a salesperson has basically sold the patient on, like, “Hey, you need this, you need that,” whatever. And then they never actually interact with a doctor. And like who you are, and someone like you who’s working with them from the beginning because everyone is different.
Dr. Danyo: Well, I think it’s really important…if you’re African American, thinking of hair transplant and you go to a consult, I think the maximum that you can get harvested at one time from the donor site for men is 2,000 grafts unless you have really high density. One issue is that with African American or African-style hair, it’s more coarse and curly. So, the coarseness and the curliness makes up volume-wise for having a reduced density relative to, say, Caucasian or Asian. So, what I’m trying to say is there just aren’t as many graphs that are available to take from your donor site, but the good news is that each graft, because it’s curly and coarse, covers a lot more territory.
So, you don’t need as many grafts. But if you have a consult and somebody says, “Oh, you need 3,000 grafts,” I would run. They could potentially permanently damage your donor sites. And it’s important that that never happens. If you need more, you just have to break up the procedure by six months. You can go back in after the first one and after things have healed, it contracts back in and you can grab more, but 2,000 is the max for the guys and really 1,500 for women is about the max at one time.
Clark: Let me ask you this. Are there ever instances when someone messages you and say, “Hey, you know, I’ve been searching around and trying to find the right solution for me and this one person I talked to, this one other practice, whatever, they said what you just told me, like, ‘Oh, something didn’t feel right.'” Sometimes do people come to you saying, “I’ve been talking to someone else and it just didn’t feel right.” And then you end up basically telling them, “Hey, you need to be very careful. You need to run if I was you based on what you’re describing to me.” Does that ever happen?
Dr. Danyo: I try and shy away from bad-mouthing individual providers. It’s not that I wasn’t part of the consultation and things like that, but I do try and say, “This is my philosophy on things and I generally recommend not doing more than 2,000.” If this person recommended 3,000, potentially, that could be difficult for your donor sites, and I would split it up. You potentially need 3,000, but not at one time. It’s gonna be safe to just…let’s do 2,000 and then 6 months later, we can do 1,000, and then your donor site is gonna heal fine. And in the end, you’ll be much happier than getting 3,000 all at one time. That’s the approach that I take.
Clark: Right. Hey, I know that about you. You definitely never bad-mouth anyone, and that’s just part of your values and part of the philosophy you use in the work you do.
Dr. Danyo: I think everybody has a different technique and philosophy. And I just have to present my philosophies for people. I recognize that sometimes I may not jive with people, and then other times I might. So, that’s just how I approach these situations. But I would definitely say on the podcast, that 2,000 maximum for the men and 1,500 maximum for the women.
Now, a lot of times for the guys, if they have a thick beard, especially under the chin and we wanna get more…I’ve done 2,500 where I’d take 2,000 from the back and 500 or even up to 1,000 from the beard to get to a higher number. That oftentimes works well because there’s curl in the beard hair. A lot of times it has a very similar texture and curl. And when it’s blended in, it’s really not noticeable. So, it’s like bonus graphs.
Clark: I’m always surprised when you go through all of the different strategies and different techniques that you’ve used. And I try to keep up with all the language you have here, but you do a good job, though, making it pretty easy to understand.
Dr. Danyo: Well, thanks.
Clark: Are there other things someone should be thinking about as we’re starting to round out here, our conversation? You covered a lot of great ground. What else is on your mind?
Dr. Danyo: Yeah. I think the hairline for African American men can be somewhat difficult. There can be somewhat of a tendency to bring it low just because the natural hairline is more flat. There’s sometimes hardly any recession. So, you just have to be mindful not to get into the forehead skin, especially out to the corner because the forehead skin comes up a little bit higher on the sides.
So, getting that line correct. The other is to determine whether you want this really straight line or whether you want it a little bit softer. I like doing softer hairlines. And what I’ll do is we’ll create more of a lined-out look, and then we’ll create single hair grafts that we put just a little in between the other graphs in a little above and just make it a little bit more random, not too deep as far as going away from that line, but it softens it up. That’s my favorite way of doing it.
Clark: It makes sense.
Dr. Danyo: Yeah. And then with the women with the…especially the traction alopecia…a lot of times it is a double case where we can do 1,500 max, but there may be a need to do 2,000 or even more if there’s involvement on the side or the traction alopecia goes behind the ear. That’s a large amount of graphs, usually about 750 per side. And then if the hairline needs to be taken care of as well, that could be an additional 750 graphs. So, and then one other diagnosis that we see a lot of is…it’s a tricky name. I think it’s a ridiculous name. It’s called central centrifugal cicatricial alopecia.
Clark: Oh, my gosh. What does that mean?
Dr. Danyo: Yeah. So, it’s central, meaning it’s in the center of your head, centrifugal means it starts in the middle and it spreads out in a circle. And then cicatricial means scarring and then alopecia is hair loss. So, it is a diagnosis that I’ve only seen in African American females. I’ve never seen it in men, I’ve never seen it in Caucasians or Asians. And there’s no disease associated with it, but it’s this atypical hair loss that happens in the center, top part of the head and it spreads out.
Sometimes it can spread out to where there’s just severe hair loss, and there’s not a lot that we can do from a hair transplant standpoint. And then other times it’s smaller. But anytime I diagnose this CCCA or central centrifugal cicatricial alopecia, I do a test graft of about 100 grafts first because it is a scarring alopecia and there’s a potential that when you move those grafts in there that the process could also eat up those grafts. And I wouldn’t wanna do a big procedure and then it not work. So, we generally would do a test case first.
Clark: Right. And scarring is something that you got to be really careful about and how you approach that and how that happens. There’s a lot here.
Dr. Danyo: Yeah. The scarring alopecia, the stem cells get attacked and the hair will never grow. So, the treatment is hair transplant, but in this scenario, you should do a test graft case first of about 100 grafts just to make sure that if you do more that they’re not gonna be eaten up. And I’ll even do…we’ll do, let’s say somebody needed 1,000 grafts, I do a 100 first, come back in 6 months do 500 if that worked out well, and then I’d finished the rest out 6 months later. Again, you just never know. There’s always a potential it could be reactivated and you just don’t wanna do a massive procedure, it could stress out the scalp, have a higher chance of reactivation, or if that happens, and 1,000 grafts are gone, that would not be good.
Clark: Right. That would not be good. And this is yet again, really insightful to be thinking about. And just the fact that you would give it some time and wait, it just shows that this is not a hurry up and go thing. Your number one priority, of course, is your patient. And we’ve talked about this in the past several times. Well, Dr. Danyo, this has been another great conversation. I really appreciate you always taking the time to go through this variety of topics that we always dig into together. So…
Dr. Danyo: Yeah.
Clark: Thank you. And I’m looking forward to the next session.
Dr. Danyo: Likewise. Another great discussion. Great topic.
Clark: Hey, thanks for listening to “Hair Restoration with Dr. Daniel A. Danyo.” Book your consultation today with Dr. Danyo by calling 678-845-7521, or visit them online at nahairrestoration.com. And be sure to follow, 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.