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Question for hairsite----or anyone who knows for sure--donutting time


#1

In a discussion, the issue of donutting has come up in the old 4 mm plug grafts. Does anyone know how long it takes for donutting to occur in these grafts???

Also, does anyone have any explanation for why the donutting occurs? Has the explanation been updated in any way? Thanks all…


#2

» In a discussion, the issue of donutting has come up in the
» old 4 mm plug grafts. Does anyone know how long it takes for donutting to
» occur in these grafts???
»
»
»
»
» Also, does anyone have any explanation for why the donutting occurs? Has
» the explanation been updated in any way? Thanks all…

Dr. Cole wrote an article explaining donutting and some of the other complications of plug grafts.

» Evolving Aesthetics of Hair Transplantation

"For the first 20 to 25 years of hair transplantation, 3-4mm (millimeter) round, “plug” grafts were the standard units generally placed in balding areas. These were felt to be the optimal size grafts in terms of density (hairs per square mm) and in terms of blood flow (nourishment) to the tissues of the graft. In other words, these grafts, with 12 to 20 hairs each, could achieve high density in the recipient (balding) area; also, bigger grafts would be easier to move, but re-establishing their blood flow, especially toward the center of the grafts, would be tricky. Later, this was found to be a problem even with these standard grafts, and sometimes the hairs in the very center of the graft would die, leading to the appearance of a hole in the middle, hence the term “donutting”.

Other cosmetic problems were soon recognized. Often, a raised area at the base of the graft led to the aptly named “cobblestoning” effect. Probably the most widely recognized negative effect is the so-called “doll’s hair” “toothbrush” or “cornrow” appearance. This results from a dense, round graft set in the midst of bald scalp; the effect is worsened by the fact that, as the graft heals in place, scarring causes it to contract. This increases the density (compresses the hairs into a bundle) even more, to a level not found anywhere on the head, therefore appearing unnatural. When these round grafts were placed at the frontal hairline, they often appeared as an inhumanly straight, regular row, which is not the way hairs grow in nature. Furthermore, if the patient’s balding progressed, these grafts stood out even more, to the point of becoming a cosmetic nightmare. Also, if the hair behind the grafts was lost, there developed an unnatural look further back in the scalp; this appears as a posterior, or “rear” hairline. In addition, the normal, natural direction of hair growth was not honored. Hair from the crown up to the front grows in a generally forward direction; there is a “whorl”, or circular effect at the crown, and at the temples the hair abruptly changes to a downward, and then backward, direction. Often the large grafts pointed up at right angles regardless of location, which added to the less than natural appearance, and could severely limit styling options. From a logistical standpoint, grafting with standard plugs could be a nightmare."
-John P. Cole

You had also asked, “Does anyone know how long it takes for donutting to occur in these grafts???”

Dr. Cole explains that donutting occurs due to lack of circulation in the center of the graft. Re-establishment of circulation begins immediately after the graft is placed and continues throughout the healing process. Generally, by the second week circulation should be well established, depending on the patient’s individual healing characteristics and activities during the initial healing phases.


#3

Thank you Jessica,.

Bryan Shelton and I and Docj077 and Wookie are discussing why donutting occurs in relation to Foote’s hydraulic theory of hairloss (which Bryan, me, and Doc dont agree with). Stephen Foote contends that donutting occurs over about a six year period slowly as edema rises in the scalp due to lymphatic over-pumping by overstimulation of DHT and as the pressure spreads, the hairs in the center of the grafts can’t re-enlarge due to contact inhibiton because they are not protected by a scarring scaffold created around smaller grafts, and this is why only the grafts on the outermost portion of the old big 4-5mm plugs lived permanently. The verbiage about these large grafts contracting on scar healing makes the hypoxia explanation as to why the centers donut-out alot more palatable and understandable. I had even wondered why donutting occured myself as if the hairs grew once up there in the graft centers, they should grow twice et cetera. If the grafts contract over the years however, this question is answered completely for me personally (although I doubt anything will convince Foote).

Do you know, or does anyone know, how long this phenomena takes to fully happen? I was assuming 2-3 years, but Ive read some people claiming that it happens rather quickly, and some saying it happens over more than five years. Since these aren’t done anymore (thank God), its hard to find out just how long it takes for donutting to take place.

Thanks for your response and info…the guys will appreciate it.


#4

I guess plug grafts would be subject to donutting at several stages in the maturation process. Initially if the center of the graft was not able to establish circulation, it would donut rather quickly. I would say in the first couple of weeks.

Then there is also danger in the later stages of healing where scarring causes the punch graft to contract. The contraction could strangle any circulation that was initially established, creating the hypoxia, as you had stated. This could happen anytime in the first year as changes to the tissue mature and settle.

Foote does have an interesting point. However, I don’t agree that the edema-DHT-lymphatic pressure idea would cause the donutting. But rather that the contraction of the graft can complicate the normal life cycle morphology of the hair. This might then lead to the inflammatory response that Foote is talking about.

During the anagen or growing phase of the hair, the root of the follicle extends down to the subcutaneous tissues. The cells of the follicle are hypertrophic and active. This phase lasts about 7 years on the scalp. But when the hair goes into telogen or resting phase, the entire follicle crenates and shrinks up towards the surface of the scalp. Contraction of the graft due to scarring could interfere as the telogen hair begins into the anagen phase again. There might not be room for the follicle to expand into it’s active form again. This phenomenon would be seen at around 6 or 7 years.

It is possible that this could cause inflammatory edema secondary to the follicle being compressed. There has been research that shows higher concentration of DHT in areas of inflammation on the scalp. The lymphatic pumps would be active due to the inflammatory response to deliver extra white blood cells.

Foote might be on the right track, but it seems a bit backwards in the mechanism flow. The answer is that Foote should have talked to Dr. Cole’s assistant Jessica before publishing his hydraulic theory to get the details right. Hahaha! Just kidding! I’m just speculating as to what I think might be happening. :smiley:

I’m pretty sure that we don’t know enough about the cellular mechanisms within the follicle to know this kind of stuff for sure. But perhaps this could initiate some research. Could some one get a grant and find out for us?


#5

Thank you Jessica…I’ll more or less cut and past this excellent for the guys.


#6

Did anyone ever have a decent result from plug grafts ?


#7

» In a discussion on another board, the issue of donutting has come up in the
» old 4 mm plug grafts. Does anyone know how long it takes for donutting to
» occur in these grafts???
»
»
»
»
» Also, does anyone have any explanation for why the donutting occurs? Has
» the explanation been updated in any way? Thanks all…

If I remember correct, donutting was because the central part of the graft did not get nutrition in time. Thats why you never hear 5 or 6 mm plugs. 4 mm was the limit.
If donutting has to occur, I will expect it within the first year. Unless the grafts were taken from unsafe scalp area.


#8

» Did anyone ever have a decent result from plug grafts ?

Let me surprise you. There are people who are actually satisfied with plugs.
I happened to meet one a few days ago.
That is because he seriously doesnt know anything better is possible. Its a catch 22 situation. Do you tell them that better is possible or do you let them remain happy in their present blissful ignorance.
We choose the latter. But, we give them links where they can educate themselves. Seriously, theres no easy way to break the news to them. If you find one, I would be happy to hear.


#9

I can remember seeing real old Bosley productions on “public tv” in the eighties. None of the patients I saw previewed were completely bald, but rather were thinning or in the earlier stages of MPB.

When they would show the post-op pics one year later, the guys all looked better because of the increase in density, however, I never saw anyone who had his hairline reconstructed with plugs.

The fundamental problem is that plugs have no aesthetic benefit or appeal so when these guys began to lose their natural hair “around the plugs” they stood out like sore thumbs.

No Propecia back in those days.


#10

Sorry this is late benji from Dr. Harris. He just answered it.

"Tom,

Sorry, my filter has been sending your e-mails to the junk file.

Donutting typically becomes evident during the regrowth (6-12 months) period
after transplanting. The most logical explanation based on this observation
is that something occurs after transplantation that affects growth of
follicles in a certain position in these larger grafts. The most logical
explanation is the lack oxygen diffusion during the grafts early
revascularization process.

The scar maturation during subsequent years may have some impact but it is
probably a secondary consideration. I doubt that after the first year
changes in lymphatic flow have any role. If they did all the grafts would
start puffing up. High lymphatic pressures have never been shown to cause
hair loss. In my previous life when both jugular veins had to be sacrificed
for some reason the head would swell to enormous proportions and none of my
patients ever experienced hair loss.

Dr. H"