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  #11   Top  
Old 07-06-2012, 02:09 PM
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formertrackstar,

No idea about cost. I haven't had this done. Just going by what their site says. According to them, this is NOT a permanent procedure (which is why it's appealing to some). If you do the math, you'd have to have at least 5 procedures done in a ten year period. But odds are you'd be looking at 10 - one per year - if you want to maintain the illusion consistently.

You should contact Jotronic directly about this company. Also, shoot the company an email with questions although communication may be a little shaky, because of the language barrier.

z
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Old 07-07-2012, 05:18 PM
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Yes, we have been in contact with FTS. We probably would recommend a scar revision, then possibly SMP, but very likely the SMP may not be needed. If one is considering more work in the near future, why do it, other than for a more conservative and temporary fix, in reducing contrast. SMP, without reducing the gap ultimately, in the long run, will not be as helpful, plus when the day comes to do more work the scar is going to reduce the yield.

FTS, as he has indicated had two previous sessions from another clinic, therefore we were dealing with the circumstances of that work. Which was a scar similar to what you are seeing. In many cases we may have been able to yield the grafts needed and reduced the scar. The previous scar was primarily behind his ears and he indicated he did not what to go longer to get the grafts. It was decided to extend it a bit but minimal. The length of the strip is generally not the concern it is the width, that can causes problems.

The scar at this time should not be difficult to improve, possibly to a fine line, which is the case for most of our virgin patients. Industry's standard is 1-3mm. The difference is with a scar revision is, one goes only after the scar tissue, and not for hair also, so the width is less and the tension is less. Nearly a fifth of our work monthly is corrective work, and we restore the great majority of these patients to a very respectable look, but they are not the same as a virgin patient.

Our method of closure is generally a double-layer closure using internal sutures underneath and removable sutures or staple on the outside. This closure maintains the integrity of the scalp above and below and holds the scalp together under more tension. In general this method is capable of producing a finer scar, which should allow most patients to wear their hair quite short, approx. half inch. If there is a desire to try to wear the hair even shorter, FUE into the scar and then possibly SMP could be considered. We have had less than 3% of our FUT patients feel the need to pursue these added measures. With the industry evolving and patients getting pickier and pickier, more may!!!

Regards, Matt
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Last edited by Zup; 07-07-2012 at 08:45 PM.
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Old 07-07-2012, 07:47 PM
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I just sent formertrackstar an e-mail asking him to call me when he has a chance so I can go over the different options I think are available to him. I understand his anxiety about having another incision made in his donor area. Even though there is a good possibility it may help …..there is a risk it may not.

Because of this and because of what I currently know about SMP….. I would recommend SMP to him at this time.

I have been following the results of SMP the last 2 to 3 years & I think it is a good tool. It still in its infancy and we are learning more and more about it as time goes on

Having said that,…. I've seen a number of people who have had scars just like formertrackstar, who have had SMP done and the majority were very happy. The degree of camouflage varied slightly but in all cases the scar was much harder to detect even with the hair short.

In remotetrackstars specific situation...... Because he has anxiety about a scar reduction, I think that using SMP is the best choice to meet his immediate needs with very little risk.

ONE pearl when doing SMP in the donor area is “not just do the scar” but to blend it through the entire donor area fading away as one gets near upper and lower borders of the donor area.

I have seen SMP scar repairs done by all three clinics mentioned in this thread (Rassman, GLI, BELLA MEDICAL (of italy). The patients in all three clinics were happy they have had it done.

Last month when I lecture that the Italian society of hair restoration annual conference in Rome...... Bella medical was there. Theygave a one half day seminar and demonstration on thier technique. I attended it and was quite impressed with their technique. I am even considering going over to Milan for a coursethey are offering to learn how to do it and bring it back to the states.

There are advantages and disadvantages to the fact that the pigment will slowly fade over time. The main advantage is....in the remote chance that the patient does not like the results….. He knows he will not be stuck with it forever. Also you don't have to worry about the issue of the ink changing color.

The negative is that it probably has to be repeated every couple of years.

If I start to do this I would probably use the temporary ink on patients that are very nervous about the permanency. On patients whether this was less of a problem I would consider using more permanent ink. However this is all theoretical as most of the companies except for Bella medical and very secretive about their techniques and it's been hard for me to learn as much as I would like to so I can relay the information to patients.


In former track star's case, because this is bothering him so much…. I think he would get near immediately improvement with SMP.….. with little risk. It would not rule out the possibility of doing a scar revision and more work in the future if he became more comfortable with that option.

There's a lot more I could say on this because there are many nuances to this technique that are revealing themselves as more cases are done. As I learn more I will pass it on to you


I've asked former track star give me a call at his convenience because it is easier to discuss all the positive and negative aspects of this complicated issue over the phone
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Old 07-07-2012, 08:24 PM
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By the way,.....I understand Zups logic from a "purely surgical and technical" ""standpoint....but it does not take into concideration FTS anxiety about another incision....or the near immediate improvement FTS could get from SMP. Each patient is different. In some cases a scar revision would be the first step. In others FUE. In my opinion for FTS case, SMP would be the best due mostly to his concern over another incision. Because he had two previous surgeries before he came to us for a repair. So his donor is no longer virgin and less predictable. On the last surgery we took out scar + hair. In a scar revision the incision would be not as wide and theoretically may have less chance of wide scar. But because it is not 100% sure and because of FTS concern I lean toward SMP at this stage.
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Old 07-08-2012, 09:21 AM
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I had an average scar on the left side of my head from a strip job done in 1989. I filled it with leg hair - or tried to - and it was still obvious, but by no means that bad as far as they go. It was flat and white, smooth and well blended with the contours of the scalp.

In 2009, I took some advice against my natural sense from a well respected doctor. He suggested opening it up again. I must say - the goal was to get more grafts, not eliminate the scar, which as I say, was far from bad as old strip scars go.

This time it was a double layered, tricho. It was cut out very slowly. The inner sutures were sown in as we went. I was impressed at the delicacy of the procedure, but shocked badly at the result. It is bumpy, pink, slightly stretched in some areas and very, obvious. And to make matters worse, all revisions lengthen the scar and mine was no exception.

The message is clear. Don't do a revision unless you like to gamble! and gamble big time.

I would suggest SMP the scar first. Then add some body hair or FUE scalp hair for texture, and then, only then consider a revision, whereby they would remove all the SMP anyway.

With SMP in scars there are two variables.
First, the scar might just bounce the ink off. It might not absorb the ink.
So big deal you say? It will fade and nothing lost. You could be wrong.
If the artist applies ink to the surrounding area of the scar, in an attempt to blend the scar - you might look even worse, because after a month of fade, the areas immediately above and below the scars will look even darker in comparison to the scar. The SMP may actually have the reverse effect - highlighting the scar!

So you have to see if the ink will sit in the scar - but you can't, because it is not practical. you can't be going to the clinic 12 times to see how it works in different areas of the scar.

So there is a risk. My advice. Limit the amount of surrounding tissue tattoed. SMP the scar. It will look too dark for a while. Re-asses after a month or two and then add the necessary ink above and below if desired.

The other variable is hair length. Incredibly, I have to buzz the scar shorter than the surrounding hair for it to blend - I say 'blend', cause it is far from perfect.

And then of course we get into the parameters the artist uses. Depth, pressure, timing, ink graduation.

I've had three shots at SMPing my scars now. Starting from 2003. Knowing what I know now, I might have done it a lot better. but I still don't know about ink, and they won't tell me diddly about it either.
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Old 07-08-2012, 10:16 AM
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Dr. Shapiro,

Thank you for checking in on this matter. We have a situation where there is a market demand (among those with HTs, especially scars) for revision. We have these companies cropping up offering these services but as Scar5 said there is this "secret" sub-cuture among the inks and methods. It gets to the point of ridiculous. Ex. GLI basically insisting all the time on their "trans-dermal hair replication" method, etc.. The lack of transparent pictures among some providers. The non-regulation of the ink being put in people's scalp. The horrific overpricing for what is essentially a tattoo. Since Shapiro Medical is among the leading thinkers, I think the challenge is to take a conservative approach and perhaps you might think about offering this service yourselves in-house. Specifically, putting temporary ink (that you know where it comes from and is considered safe) in the scars/scalp (that can be patch tested first) at a reasonable price (I am sorry, but scars should not cost $2500 as some places charge) that would allow folks to have the service and come back once a year for re-application. I feel this is achievable and reasonable and if you can offer this service under your brand then the people will come. We really need a pioneer like yourself to help take this issue to the next level and away from these early dark days. Hope you might consider this. Thanks.
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Old 07-08-2012, 12:07 PM
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Davis91, yes this is something we are considering.....we now have meet in person and gathered knowledge from NHI, GLI, and the temporary ink group from Milan. We know this could be a nice adjunct with transplantation for many patients, with the impressions serving to give the appearance of better coverage and density. By doing this in house, we're more in control. Allowing us to plan this out with the patient for the best and safest approach both short and long term; treating and placing each impression as carefully as we do ones limited donor, with the addition of anesthesia. We take time to incorporate new things, so that many of the kinks have been worked out, to minimize added risks to hopeful patients.

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Last edited by Zup; 07-08-2012 at 07:57 PM.
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Old 07-08-2012, 01:54 PM
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I agree some of the comments by Davis 91 and Scar 5.
It has been frustrating getting answers from different SMP companies that perform the procedure. They are very paranoid that someone is going to "steal" their process.
Sometimes I wonder if the process is that much different between them or they just want to create an illusion of a difference. They talk about different needle size, different depth, different inks, etc. The only two that have been totally open , which I respect, have been Rassman (who has let me watch him) and the Bella Medical (who have let me watch them).

Rassman alluded to the fact that although technique and equipment is important…… you need experience and a feel to get the right depth and consistency of the pigment. To his way of thinking, this was just as important as the machine and needle that is used. He is conservative and from trial and error has begun to know who he can help and who he can’t.....I trust his judgment.

GLI basically won’t tell me much of anything....but because they are close to me I get to work with them on some patients....I have seen their results improve over the past 3 years....once again probably due to learning from mistakes. In the beginning I did not think their "dot" was tight enough or consistent enough and I saw a little bluish tinge. Lately their results have been really good with the pigmented dots very tight and discrete. They have been using lighter shades of black (a more greyish black) that seems to look good with most brown to black hair colors. I am still not sure about long term color changes(how often it occurs) but they say it is less. The new theory is that they not imitating the surface color as much as the color observed by the eye when the hair is just entering and a millimeter below the skin. The optical explanation I have heard is that refraction of light makes most hair shafts look sort of a blackish, greyish at this level.
On my patients I send to GLI I make sure they stay behind the hairline and do not create a wall. GLI have done a good job on the few I worked with them of keeping it lighter there.

Bella Medical I just saw does one case and I have to say that initially post op it looked really great...

Scar 5 is right about the trickiness of having ink stay in scar....It will. But you have to do a little conservative trial and error to see what depth and density will work... He is right that if you do too much on the sides it and not in the scar it will just increases contrast. But if you just do it in the scare the scar can stand out only darker.....there is an end goal to get the scar and surrounding tissue about the same shade and this looks goodMost of the scar revisions I saw looked much better after the first one but needed a few more procedures to blend.

Doing FUE into the scar as an adjunct I have not discussed that can have a couple of benefits:
· Hair in the scar giving slightly more density and texture to the scar that works well with th SMG
· Aso after transplants are done in a scar the scar tissue changes and becomes more like virgin tissue... It is like multiple small skin transplants that replace the scar and stimulate new skin.
Because of this....SMP may be easier to do in a scar that has some FUE in it first.

Although GLI is technically doing good work....they are just too secretive for me. I have offered to try and explore how to improve the use of this tool buy working together on cases and learning and adjusting. But they will not let me see their ink, tools or procedure. They get mad and refuse if a patient asks for me to come and watch. How can I totally recommend something If I don’t understand it totally. I can say that the patients we have worked together on for the most part have been glad they did it. Some very happy….some happy but hoping for a little more effect.

I did not want to just compete against them as that is not my nature. I had hoped that we could work together and learn together. But due to their secretiveness and my feeling that this is a great tool that I want to understand I know plan to learn as much as I can about it over the next year. I will start by going to Milan to learn at the Bella Medical course. thier technique. I will probably visit Rassman again if he lets me. If I feel I understand it enough I may start to offer it at our office. I think doing them in a HT office is much better for a few reasons.
· You can incorporate it with Hair Transplants on a more consistant manner and create a better Master long term plan
· You can use local anesthesia so it does not hurt
· You can combine it with FUE
I GLI starts to become less secretive and wants to work with me with total transparency I may try to work with them….but I doubt this will happen….unfortunately. By the way …I think the price is too high also. Not sure exactly what I think is appropriate but 5K seems like a lot.
With respect to scar revisions.......as a potential different approach....I would say that over 80 percent of the time if:
· the scalp is lax
· and you only go for existing scar
· and the scar is 1cm or less
· and you use acell
....you can improve it signicantly.....

Therefore if it has not been tried and the patient is comfortable with this it is usually always worth a first shot........However even though 80 percent of the time the revision works and only 20% of the time it does not work....if you have the bad luck to be in that 20% group…….. than for you it does not matter that the risk was low.....For you it happened.
Therefore a patient who undergoes a scar revision has to understand that even if everything is done perfectly ......there is that small risk...that could happen.
This I think is what happened in Scar5. He could have gotten a good result but did not.
Sometimes there are factors that can help you guess if the odds are more in favor for you or more against you.
· If your scar is not that wide and your skin is lax and you only had one procedure.....chances are good
· If you have tight skin, the scar is wider than a cm; you have had attempts before that failed, etc....the odds are worse. Scares over the mastoid process are harder to repair due to force vectors.
We now us something called Vitrase in patient with tight skin as it can create more laxity in some people.....It does not work as good in scar repair. But on people how have tighter skin on the first time and you want to try and get a slightly wider strip it is great. We also will now use Acel l in the scar during a scar repair because eit can make the tissue feel more normal as it heals.

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Old 07-08-2012, 02:13 PM
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Its better to FUE your scar using beard hair as its robust and thick plus you will be able to save your donor, you can use the hair under your chin as it wont be detectable. Try to go to Dr, Umar or Dr. Bisanga, they are top doctors in this field. Tattooing your scar wont be a good idea, you have to visit the clinic every year or two for maintenance. It sucks really.
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Old 07-08-2012, 04:59 PM
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Dr. Shapiro,

Thank you again for responding so comprehensively on this important matter. I note that you and Dr. Rassman seem to have been the only ones who have written in on this topic so extensively on these forums.

If I may ask (you or Matt), will your clinic also consider (or are you doing) body hair work? There does seem to be some consensus that beard hair, for example, is a fairly robust body hair for the scar. I can imagine a scenario where scar repair patients come to you and there is a master plan you offer based on circumstance (scar revision/or some method to soften the tissue, followed by body hair transplant, followed by SMO, etc./)

Re: pricing, $5,000 for a whole head seems obscene, and 1/2 that just for a scar is criminal. It is a complete market capture scenario at the moment. Scar repair has got to be reasonable when using SMP especially if temporary ink is used, which is probably a good idea in order to do trial and error. I would think people would be willing to pay $500-$600 per year or a little bit more to come to MN and get it done in-house with you (with plane ticket and accommodation let's say it might be $1000 total to get this done). Would the market pay $1000 per patient per year for scar repair patients to come get temporary ink into their scars knowing it is hopefully safe, non-permanent and is being done by a leading clinic? I bet it would, and those folks would be back each year over a 20 (or 30) year period. Of course, some might graduate and get a more permanent SMP solution, which is something you might eventually offer, or graduate to a revision or FUE into scar.

As for GLI, I love how they make a major deal about the better business bureau and no complaints. Well, of course: if it is all sales and marketing, and you make the client feel good, wonderful. But by the time some of the ink issues may or may not show up, it could be five, ten years for now. Also, I spoke to GLI once and they made a big deal about how they were working with Shapiro medical. I asked Janna and she said there is no official affiliation. Based on what you said Dr. Shapiro, the lack of transparency is such a red flag that you may want to warn them off using your name in a way not desired.
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