Dr. Ron Shapiro

At this point in time know one can say which technique is the best. All three physicians who have lectured on the technique have shown a range of results that are similar. Some of the scars are near invisible while others can still be seen slightly on when the hair is combed up. All three are based on the same principle and all three have been shown to work. If you poll the physicians using it it seems to be split between using the upper edge like marzola or using the lowe edge like Frechet and Rose. I have used both techniques but currently I use Dr Roses ledge tecnique the most. Since the strip is taken at an angle the uppe edge has a lip and this lip fits perfectly into the ledge created by this technique. I will on occasion trim the upper edge and usually that is if there is a pre-existing scar that has decreased the number of hairs in the lower edge. If there is less hair in the lower edge the technique is less effectiver so in this case I use the upper edge. As you can see all techniques are tools and the key is to know when to use each one. As time goes on and we get 1-2 years behind doing this tecnique and alot more patients that have had the ability to heal for 1 year than we will be better able to evaluate if there is a true difference between the techniques take care ron

It was just pointed out to me that I made a slight historical mistake in my original post about the time line of who presented the procedure first and would like to correct this for historicalaccuracy. I would like to thank Dr Cooley for pointing it out to me Dr Cooley went back to his program books from the 2004 ISHRS meeting in Vancouver in Aug 2004 and saw that Mario Marzola had indeed given a talk on this trichophytic closure at that time. Dr Marzola also gave credit to Simon Rosenbaum who had presented this idea at a previous 1999 ISHRS meeting in San Francisco. So in reality these two were the first to present the idea . Frechet and Rose on the other hand were the first to present the 'lower' edge variation of the technique. This type of historical mistake may happen from time to time as many ideas have been around for a while and often have been worked on by more than one person at around the same time. I am going to edit the original post to reflect this information. Take care Ron Shapiro

The answer is a "qualified" yes. If the scar from the first donor procedure is thin and the laxity is adequate then you can excise the first strip entirely. As Hairhope says the downside is that since part of the strip now contains scar tissue with less hair the amount of grafts will decrease. Sometimes that is not an issue as the laxity is so good that you can go wide enough to get the desired grafts and exise the scar. Also sometimes the scar is so thin that the decrease amount of hair in the scar is minimal. At other times when the scar is wider or if the laxity has decreased you have a decison as to wether to leave the scar and just go right next to it to improve your yield and then do a scar revision later ...that only adresses the scar Now if you are trying to repair a scar that is "very" wide sometimes you simply cant exise the entire scar and have to use other approaches for scar repair.(multiple small excisions, FUE into the scar, douple layer closures, and sometimes even expaners have been used for very wide scars) I think I will write a brief informational piece on the donor scarring and the approach do scar repair over the next couple of days like I did for the trichophytic closure Take care ron shapiro

I was recently asked if I perform the "Trichophytic Closure". The answer is yes. I have been using it routinely since I saw it presented at the annual European Conference in Brussels last summer (6/05). I??ve noticed that the level of knowledge and degree of interest in this closure is fairly high on this forum. So some of you may find it interesting to know more about the history, details, uses and benefits of this technique. If this type of information is useful and appears desired I will continue to do it about other subjects as time goes on. It may be helpful to open up the album I created with photo and diagrams and refer to it as you read. Photo For Trichophytic Incison Information TRICHOPHYTIC DONOR CLOSURE At that annual European Society of Hair Restoration Conference (ESHRS) that took place on 6/05, two physicians (Dr Paul Rose from the USA and Dr Patrick Frechet from France) presented two slightly different variations of trichophytic closure technique. They also referenced and gave credit to a third physician (Dr Mario Marzola from Australia) as having developed a third variation of the technique at around the same time. Dr. Marzola was not present at the European Conference. However, Dr. Marzola did present his variation of the trichophytic technique one year before at the Annual International Society of Hair Restoration Meeting (ISHRS) in Vancouver, Canada. These three physicians are each given credit for introducing the technique of the trichophytic closure to the field of Hair Restoration Surgery. Although relatively new to hair restoration a trichophytic incision is not new to the field of plastic surgery. The idea was actually used in brow lift and other cosmetic surgeries where skin bordered hair in the past. In order to hide a scar created from an incision at the border of the hairline in a brow lift, the initial incision was not made parallel to the hair, but instead, angled the opposite direction (against the grain). This direction of the incision angle transected the follicles and the hope was that these follicles would grow back through and hide the scar. This technique was probably first described by Dr Juri from South America around 1979. It worked well for brow lifts and flaps and one may wonder why it was not thought of to use during donor harvesting in hair transplantation sooner. If you think about it the answer becomes fairly obvious. One of our primary goals when harvesting donor tissue is to NOT TRANSECT HAIRS. If you transect hairs follicles too far down on the shaft a significant percentage won't grow or may be lost during the rest of the graft preparation process. The bottom line is that significant transection during donor harvesting can diminishes the patient's precious and limited supply of donor hair and thereby limits the ultimate amount of coverage and density he can obtain. A lot of practice goes into developing the skill to make the initial donor incisions parallel to the hair in order not to transect them. A skilled practitioner using proper technique can keep his transection rate down to 1-3 percent. Let's get back to the trichophytic closure in donor harvesting. As you can see, we cannot make the initial incision when harvesting donor tissue a trichophytic incision that goes against the grain. Too much transection would occur at too deep a level and potentially ruin the donor supply. However the idea came to a few people in the field (Dr Rose, Dr Frechet, and Dr Marzola) to make the initial incisions parallel to the hair follicles, and then, on one side of the resulting wound, make a second "trichophytic" incision in a very controlled fashion , that trims off a thin strip of epithelium and with it the tips of the hair follicles below. This trimming right below the epithelium is still very high on the hair shaft and does not create any transection that can lead to decreased hair growth. It is controlled transaction very high up on the hair shaft. Then of course the edges are pulled together with the untrimmed side covering the trimmed hairs so the hairs will grow up through and scar and hide it. DIFFERENCES BETWEEN FRECHET, ROSE AND MARZOLA TRICHOPHYTIC CLOSURES (Figures 1, 2, amd 3 in album) Photo For Trichophytic Incison Information There are slight difference between how the above three physicians perform there closure. At this time we do not know whose technique is best ....but all three make an improvement in the appearance of the scar. One of the major differences is that Dr Marzola trims the upper edge of the incision while Dr Frechet and Dr Rose trim the lower edge of the incision. Although both Dr Rose and Dr Frechet trim the lower edge of the incisions, their respective techniques vary slightly with respect to method that they use to trim away the tissue from the lower edge of the incision. Dr Rose uses a scalpel and first scores the entire length of the incision about 1mm back from the edge. He then uses the scalpel to trims away this 1mm wide piece of tissue just below the epithelium (~1mm deep) so as to only cut off the tip of the hair follicle. It actually looks like he created a ledge or step off with exposed hair shafts hence his name "The ledge technique" On the other hand Dr Frechet uses a surgical scissor rather than a scalpel to simply trim away the edge of the epithelium from the lower edge. Another difference unique to Dr Frechet is that he also does some minor undermining at the level of the epidermis just below the roots. He feels this further loosen up the skin for a non -tension closure. Dr Rose and Dr Marzola do not feel this undermining is necessary. The differences between the three trichophytic techniques are minor and all three have helped improve the appearance of donor scars. ADDITIONAL POINTS RELATED TO THE TRICHOPHTIC CLOSURE "?? The primary method a trichophytic closure limits the visibility of a scar is by the camouflage that occurs when hairs grow through the scar. (Figure 4 and 5 in album) Photo For Trichophytic Incison Information "?? A second hypothetical method in which this closure may work is by a postulated "anchoring effect" that may occur. It is theorized that if all the tiny little hairs start growing through the wound edge early they may act as multiple tiny little anchors or "micro sutures" and give extra support to the closure that lasts even after the sutures are removed. "?? For scar revisions the use of the trichophytic closure is more variable. It may be effective if the pre-existing scar is thin, there is sufficient laxity remaining, and the entire scar can be excised with limited tension, than it may work well. However if the pre-existing scar is wide and there is decreased laxity than the technique may be less affective for the following reasons. The decreased laxity may make it impossible to remove the entire scar at once. The decreased laxity will increase wound tension and the potential for the new scar to stretch out again. Finally, \the edge of wounds in a scar may have less hair present to grow through which limits the effectiveness of the trichophytic closure. "?? The Trichophytic closure is not a magic technique that will automatically create a less visible scar if these other rules are not followed. All three innovators of the technique still emphasize that it is still necessary to use all the rules and methods usually employed to create fine scars. (i.e. limit wound tension, create good skin approximation, properly space sutures or staples, etc). As stated above the trichophytic closure does not limit the width of a scar but instead, primarily masks a scar by letting hair grow through it. Since only a 1 to 2 mm wide zone of epithelium is trimmed away, and this creates only a 1-2 mm width of exposed follicles, the trichophytic incision works best when the scar resulting from the donor incision is 1-2 mm or less. When this occurs the results can be amazing and with the scar being nearly undetectable even with the hair cut short. However if the underlying scar resulting from the donor incision is wider than 1-2 mm, for whatever reason, the benefit is less dramatic. There are a number of reasons why a scar may occasionally end up being wider than expected. This is true no matter what technique is used and no matter who the surgeon is. Figures 6 and 7, in the album show examples of trichophytic closures. Figures 8 and 9 in the album shows examples of non-trichophytic closures. Photo For Trichophytic Incison Information "?? By far the most common cause of a wider than expected scar is misjudging donor laxity and taking out a strip that causes excess tension on a wound. One reason why the old dogma exists about limiting donor strip size to 1 cm is because it is safe. It is known that nearly 100 percent of patients will not have increased tension if you limit your strip width to 1 cm or less. As you go wider the potential for increased tension and therefore a wider scar goes up. This does not mean you cannot take wider strips, as is obvious by the number of cases being done with wider strips, without significant scaring. But it does mean that you have to use good clinical judgment when deciding who can have wider strips and how wide of a strip is safe. One of the difficulties with trying to predict safe maximum strip widths is the exponential change in tension that begins to occur with very minor increases in width at a certain point (or threshold). To visualize this concept think of a rubber band being stretched. At first you can stretch it quite far very easily but after a certain amount of stretch the tension suddenly increases and goes up dramatically when stretched just a little bit more. Another analogy that may help visualize this concept is that of packing a suitcase. One can put quite a bit of clothes into the suitcase and it will close easily. But then at a certain point (or threshold) even adding one more shirt may prevent it from closing without a struggle. With harvesting donor tissue it is the same thing ....the donor may close easily at a certain width but at a certain point, when you take out just 1 -2 mm more it may suddenly create a dramatic increase in tension and become hard to close. Dr. Mel Mayer has attempted to develop a testing method for predicting laxity and safe donor widths that he has presented at conferences for the last 3 years. He makes two dots on the donor area about 1 cm apart and pushes the dots together to measures how much they move. Depending on how much the dots move he developed a formula that suggest safe widths ranging from 1-2 cm. So far aside from clinical experience and judgment this is the best we have. "?? The ability to predict safe maximum strip widths has become particularly important over the last few years because in order to get the larger sessions that are becoming more popular, a donor strip often has to be greater than 1 cm. It think the old dogma of keeping strip length to 1cm or less in everyone was too conservative For example last week I did two cases that were both 4000 + grafts each. I had to make an incision 1.6 cm wide on one and 1.75 cm on the other. But both patients fit my criteria for taking wider strips as they both had tremendous laxity and good donor density. In addition they were both aware of the relative risk (or potential) for a slightly wider scar and they were willing to accept this risk. On the other hand if they had not satisfied my criteria (i.e. - poorer laxity, poor donor density, an increased concern of even a small scar in the donor area, the desire to wear a crew cut, young age with the risk of significant donor hair loss in the future, etc) then I would have suggested a more conservative approach. Many patients may be candidates for wider donor strips. How wide will vary in different patients. For some it may be too risky to take wider strips while for others it is not. It is important for you as patients to understand the thought process and the criteria physicians use to make these decisions. The same is true when it comes to other currently controversial aspects of the procedure such as doing larger sessions and higher densities. Larger sessions and higher densities can be done and are powerful tools for us to use in the right candidates. However everyone is not the same and everyone is not a candidate. The criteria we use to decide what to do on different patients needs to be shared and understood. I know I am beginning to touch on some controversial issues here. I have a lot of thoughts on them and if it is desired I will continue to share them in future posts. For the record I want to state that I am not dogmatic and look at different techniques as tools tool to be added to a physicians armamentarium to be used in the right situations. I think it is important for patients to begin to develop a feel for how different physicians make these types of decisions. For now when my patient post I will encourage them to give the details of the procedure as well as any criteria I may have used to choose a specific approach. With respect to the donor area I will give them my estimate of donor laxity, donor density, total donor supply as well as the length and width of the strip used. . With respect to the recipient area I will give them the total number of grafts, the total number of hairs, the total breakdown of grafts (1's, 2's, and 3's), the total area transplanted. When referring to densities I will try and be specific about the different densities produced in different areas of the recipient area as the density is not consistent throughout. Take care Ron Shapiro

The following are some photo and diagrams that may be useful to refer to when reading the recent post I sent called "Informaiton on the Trichphytici Incision" I hope they are educational and helpful in understanding this technique [/url]

I see the need to get some photo and patients demonstrating my brothers work on the site so people can get an idea of the quality. He has been studiing it for about 7 years now and actually doing procedures for about 4 now. I think his work is looking great....I get a little jelous when I think it begins to look like mine....but oh well sibling rivalry. I will have paul contact 2-3 of his patients and get them to tell about thier experience as well as get the photo of these patients into a album on the Forum I want to emphasize that I am personally available to do any one that wants to have work done by me and we do not change Drs on anyone. However I only do 1 surgery a day and there are only so many days available especially when you add in lecturing and teaching I do at conferences almost 6-7 times a year. I get booked up so far in advanced that patients have to wait. I feel bad and try to make as many days available as possible. There are just so many days. So if they feel confident in my brothers tehnique and they dont want to wait as long it is offered. And I am very proud of the work he has done over the last 4 years. It is fun to see his patients coming back exited and happy. I get vicarious thrill out of seeing this. Hope this was not too personal Take care Ron shapiro

I will look into the Dragon technology. Sounds cool and it may work with the new Nextect software I am implementing at the clinic Nice hearing from you Victor . I hear you are going on vacation soon. You work so hard you deserve it. Thanks for the compliment. But you and Jerry deserve yours as well. I had a question for you if you dont mind answereing on the forum. A 3000-4000 FU session is not that difficult to do at least for me and you . But the 4500-5500-6000 sessions take more skill and technique and I think (or am curious)a specially qualified patient. When you do a 4500-5500 session what qualifications do you require. Specificall with respect to the donor area. I am also curious about how long and wide a strip do you usually need. I know it varies with donor density. The reason I asked was yesterday I did a patient who was a virgin (with respect to hair tranplants) and I felt he could use 4500+ FU. He fit my criteria for a larger session(i.e He was a type 5, no hair in the recipeint area to shock, had very very loose donor so I could take a wide strip without tension or much risk of a scar, his donor density was only average however ) So I took a strip that was about 1.8mm x28 cm wide ( usually a 1.0x25 gives me 2500 FU) and expected 4000+ but only got 3800 FU. Not a small session but I had thought I would get over 4000. The case of cource turned out great and he will look great but I was disapointed that I did not get over 4000FU this time. I have been reluctant to take strips wider than 2.0 so the only patients Ihave gotten over 4000 FU with have been those with very above average density. So I am curious about what the size of your strip is for the 4500-5000 cases. Is it the same I took but these patietns have very very good density (above average) or do you go wider sometimes if they are loose enough that you dont think the risk of tension is significant. I hope you dont mind me asking on the forum but I think knowing your approach and thought in this area would be very enlightening to all both physician and potiential patients. Take care Ron It would be educational to know and maybe it would be of interest and educational when your patients that do these very large session post to get an idea of how thier particualr donor ranked compared to average and how much was needed.

I wanted to post mudpuppy's photo on the HTN He said he had trouble posting them here I think people wanted to see them I think after seeing his initial photo it will be more obvious why we were conservative with him at that time. When he arrived at our office he had extemely short hair which influenced our evaluation. It looked as if he occiputal area might drop and his lateral donor above the ear was so thin we worried that even with a fine scar it may show. I am glad that with propecia and with letting his hair grow it looks like he will have more donor than his initial evaluation indicated. If I had seen him at the 7 month point I would most likely have estimated about 2500-2700 for his second session by the way his donor looked to me now. I hope these photo explain to a small degree why we we were more conservative with him intially Here is mudpuppy's album mudpuppy album showing inital potential poor donor As it turned out Victor(Hasson) was able to get 3200 instead of the 2500-2700 I might have done) And he did a great great job. He and Jerry(Wong) do wonderful work. Victor,Jerry and I are friends and I respect thier work tremendously. I never have an issue when patients elect to go to them becuase I know they will get great work. On another note I want to appologize for not posting as much. I have been so busy lecturing, writing, and talkng to my patients that I have not really spent alot of time on the internet. It has led to some misconceptions about my current approach which has changed alot in the last 2 years. Even my web site is over 9 years old and is out of date. For example I have done a number of cases greater than 4000 FU and have been creating 1 pass densities of 50+ for years. But I vary my approach tremendously depending on the individual. My numbers can range from 1500 over 4000 and my denisties can range from 25 to over 50 in one pass...depending on the situation and patient. Sometimes the more the better but sometimes it may not be the best choice. Over the next few months I plan on posting and sharing more how and why I approach diffent patients. I hope that patients and visitors to the forums find it helpful. I have been told I am a good teacher and have a knack for putting things in perspective . I hope that I can contribute here. The only problem is that I am so compulsive about getting things right that I can spend hours and hours on a page of text..and not finish it...Writing does not come easy to me...talking does.......However I have decided that if I am going to contribute I cannot worry about it being written perfectly. Better to contribute some even if it is not written well than not contribute at all. Hope to be in touch soon Ron Shapiro

I wanted to post mudpuppy's photo on the HTN He said he had trouble posting them here I think people wanted to see them I think after seeing his initial photo it will be more obvious why we were conservative with him at that time. When he arrived at our office he had extemely short hair which influenced our evaluation. It looked as if he occiputal area might drop and his lateral donor above the ear was so thin we worried that even with a fine scar it may show. I am glad that with propecia and with letting his hair grow it looks like he will have more donor than his initial evaluation indicated. If I had seen him at the 7 month point I would most likely have estimated about 2500-2700 for his second session by the way his donor looked to me now. I hope these photo explain to a small degree why we we were more conservative with him intially Here is mudpuppy's album mudpuppy album showing inital potential poor donor As it turned out Victor(Hasson) was able to get 3200 instead of the 2500-2700 I might have done) And he did a great great job. He and Jerry(Wong) do wonderful work. Victor,Jerry and I are friends and I respect thier work tremendously. I never have an issue when patients elect to go to them becuase I know they will get great work. On another note I want to appologize for not posting as much. I have been so busy lecturing, writing, and talkng to my patients that I have not really spent alot of time on the internet. It has led to some misconceptions about my current approach which has changed alot in the last 2 years. Even my web site is over 9 years old and is out of date. For example I have done a number of cases greater than 4000 FU and have been creating 1 pass densities of 50+ for years. But I vary my approach tremendously depending on the individual. My numbers can range from 1500 over 4000 and my denisties can range from 25 to over 50 in one pass...depending on the situation and patient. Sometimes the more the better but sometimes it may not be the best choice. Over the next few months I plan on posting and sharing more how and why I approach diffent patients. I hope that patients and visitors to the forums find it helpful. I have been told I am a good teacher and have a knack for putting things in perspective . I hope that I can contribute here. The only problem is that I am so compulsive about getting things right that I can spend hours and hours on a page of text..and not finish it...Writing does not come easy to me...talking does.......However I have decided that if I am going to contribute I cannot worry about it being written perfectly. Better to contribute some even if it is not written well than not contribute at all. Hope to be in touch soon Ron Shapiro

I wanted to post mudpuppy's photo on the HTN so people could see the reason we were conservative with him. When he arrived at our office he had extemely short hair which influenced our evaluation. It looked as if he occiputal area might drop and his lateral donor above the ear was so thin we worried that even with a fine scar it may show. I am glad that with propecia and with letting his hair grow it looks like he will have more donor than his initial evaluation indicated. If I had seen him at the 7 month point I would most likely have estimated about 2500-2700 for his second session by the way his donor looked to me now. I hope these photo explain to a small degree why we we were more conservative with him intially Here is mudpuppy's album mudpuppy album showing inital potential poor donor As it turned out Victor(Hasson) was able to get 3200 instead of the 2500-2700 I might have done) And he did a great great job. He and Jerry(Wong) do wonderful work. Victor,Jerry and I are friends and I respect thier work tremendously. I never have an issue when patients elect to go to them becuase I know they will get great work. On another note I want to appologize for not posting as much. I have been so busy lecturing, writing, and talkng to my patients that I have not really spent alot of time on the internet. It has led to some misconceptions about my current approach which has changed alot in the last 2 years. Even my web site is over 9 years old and is out of date. For example I have done a number of cases greater than 4000 FU and have been creating 1 pass densities of 50+ for years. But I vary my approach tremendously depending on the individual. My numbers can range from 1500 over 4000 and my denisties can range from 25 to over 50 in one pass...depending on the situation and patient. Sometimes the more the better but sometimes it may not be the best choice. Over the next few months I plan on posting and sharing more how and why I approach diffent patients. I hope that patients and visitors to the forums find it helpful. I have been told I am a good teacher and have a knack for putting things in perspective . I hope that I can contribute here. The only problem is that I am so compulsive about getting things right that I can spend hours and hours on a page of text..and not finish it...Writing does not come easy to me...talking does.......However I have decided that if I am going to contribute I cannot worry about it being written perfectly. Better to contribute some even if it is not written well than not contribute at all. Hope to be in touch soon Ron Shapiro

I wanted to make everone aware that Paul Rose and I have been friends and colleages for a long time and the exchange of ideas between us has helped us both improve and change our techniques over the years. I also respect Gillinators longstanding good reputation on this forum. I was not really upset or worried about the thread or comment Gil made. The only reason I mentioned something to Pauls was that after thecomment was posted I started to recieved a lot of personal e-mails asking me about it and after a while I thought I should mention it to Paul. I do not feel that he or Gil in any way did anything wrong or tried to give wrong informaton on purpose. They both have a great reputation for integrity. It was not necessary for them to write explanation on here but it shows the level of there integrety that they did. I do owe Paul Rose a debt in that it he that suggested that I try this field many years (14 years) ago. So if not for his suggestion I probobly would not be in this field I love so much right now. He has also been a good friend and we have been a great sounding board for each other with respect to the many changes that have occured in this field over the past 10 years. Any way I just wanted to make sure that everyone is ok with everthing ...I am. So like the words from that jamacain song many years ago DONT WORRY...BE HAPPY Ron Shapiro

I talked and sent an e-mail to TropiCoo after I learned he was disapointed and worried. He is bothered by the V shape and I was trying to balance being conservative with a young person[25yo] with safely meeting his expectations. It was a little more difficult becauses he has a lower than normal frontal tuft/widows peak so to flattent the hairline alot would mean coming out fairly aggressivel in the cornors. I thought we were on the same page before we started but apparently he felt I was going to be slightly more agressive and I apologise to him for this gap in communication. I do think that the results will look good and that we can fine tune the shape after this grow out if he is still not satisfied. It may take a slight increased bringing out of the angle with a slight removal of the abnormally low widows peak. I have to keep in mind his young age but I will follow him through this and try to get him were he wants if it is safe and possible. He gave me permission to post his pre and post op photo and I thought it would be helpful if he and I got feed back on what was thought about the hairline work. I always want to know if I can improve on things. I think for his age that this was pretty apropriate. We did 1800 Fu in the temporal recessions which created a density of about 50+ in this area. I would apreciate any feed back The photo are below...If they do not post I will re post and put them in a photo album thread that you can see Take care Ron Shapiro