Dr. Michael Beehner

Taurusrisen, This varies considerably from doc to doc. DURING surgery every doctor has to inject some local anesthetic ("Novocaine" being the generic word most commonly used) in the form of Lidocaine and in addition Marcaine (bupivacaine), which is a longer acting one. Those are always given in the form of a "ring block" around the scalp to numb both the donor and the recipient areas on top. Some docs use a nerve block in the area of the inside eyebrows to block the supraorbital and supratrochlear nerves, which can greatly reduce the amount of local that has to later be used. Most doctors also give some form of a cortisone steroid medication, either mixed into the solution that is "tumesced" into the scalp before the holes/slits are made or in the form of pills. In our clinic we give 60mg of Prednisone just before surgery and 40mg daily for three more days. These are given to help reduce the chance of forehead swelling after surgery. During surgery most clinics give some sort of a sedative to help allay anxiety and make the time go by faster. It also keeps the patient from getting antsy and moving around, which makes the placement of the grafts much more difficult. Some docs also give a narcotic along with the sedative, which helps raise the pain threshold. In our clinic we use subcutaneous Versed (midazolam) and IM Demerol for this purpose, which does a nice job of keeping the patient comfortable and also gives a nice amnesic effect. AFTER surgery the commonest meds given out are a few days of prednisone or another steroid (Medrol Dose-pak) for swelling, some pain pills (to use if needed) and something for sleep. Some clinics routinely give antibiotics also, even though there is no proof they help, except in the case of diabetics and persons with immune problems. No doubt the reason you bring up the impotence issue is because of the drug FINASTERIDE (Propecia or Proscar), which is probably our best medication for slowing down hair loss and actually increasing hair mass in about a third of those using it. Many men who have a HT have already been on this med for some time and simply continue taking it. If not, some in fact are started around the same time as the transplant in order to maximize or increase the contribution of the native hair to the overall cosmetic appearance. Studies show a 2.9% incidence of sexual side effects (the commonest being reduced erection or reduced libido) which is pretty darn low. The hair surgeon you go to will undoubtedly tell you of its benefits and also the small incidence of side effects and then you are free to go on it or not. I can tell you that the patients that do both (HT's AND Finasteride) often have spectacular results later on, that wouldn't have been so with only the HT's. You end up with an ADDITION of two things (HT's and increased native hair) versus a SUBTRACTION if you don't use finasteride (the transplants are a plus over time, but subtracted is the progression of male pattern baldness and the loss of the remaining native hairs. Mike Beehner, M.D.

Sorry, I didn't take a post-op photo of the eyebrows as I do on all of my full eyebrow cases. I can tell you that the 30 one-hair grafts that I did place were scattered into tiny areas that were thin or missing some "mass" of hairs. We will touch it up once more when she returns. I have attached two photos of two different women, whose eyebrow transplant photos WERE taken immediately after surgery, in case you just wanted to see what eyebrow recipient sites looked like post-op the next day. Mike Beehner, M.D.

This 51 y/o female presented 11 months ago for her initial hair tranpslant surgery to correct an obvious brow-lift scar that existed at the front hair line and extended down into both temple recession areas. She also had over-plucked her right eyebrow over the years and asked that we put 20-30 FU's into that area, which we did. (Final set of photos shows change over 11 months in that eyebrow.) Her surgery consisted of 1256 FU's, dense-packed into the front hairline and temple areas. One photo shows the sites immediately after surgery. We used methylene blue dye to help mark the spots, which goes away within 2-3 days, but does give a darkish appearance to the sites. Her receipient sites were made exclusively with 0.8, 0.9, and 1.0mm custom lateral slit blades. Before and after photos from various views are shown, along with the drawing of where we set the hairline. Note that we tried to take her flat front hairline contour and give it a little more forward, rounded, and flared appearance with a normal curve into the temples, taking away the male-appearing recessions. The patient was very pleased, and in two weeks will have a final session of around 1000 FU's to increase density and hopefully finish up the job. Mike Beehner, M.D.

We usually take only two sessions to complete the side temple areas, but he had a large almost totally bald frontal area, which we took three sessions in trying to add density. Whenever I am working on that area or the crown in back or whatever, I almost always try and put a couple of hundred FU's in and around the hairline border or the temple border to make them even better. His temples were essentially done in two sessions with around 430 FU's each side between the two sessions, and 35-40 were added to each side on the third surgery just to "spruce" them up a bit. His surgery was started in 2003 and our surgery session sizes have increased quite a bit since then, so there's a chance we could have pulled all of this off in two sessions if he walked in the door today. I will attach here a before and after photo from the front-oblique angle, which shows the amount of filling in that was needed to complete the frontal region. Mike Beehner, M.D.

Mercury, In reply to your question as to whether the same type of donor hairs (from the same place) were used in the side temples as on top, the answer is that they are all from the same place, mostly from the rear flat wall of the scalp in back and then just around the corner on each side around half way up. His hair is obviously wavy and curly. How curly the transplanted hair will be later on,regardless of where it is placed, is largely a function of how long the patient lets it grow out. Temple hair is usually kept somewhat trimmed down and so doesn't exhibit as much "wild" curls as the top area might, where it is usually left a little longer to overlap and be directed either toward the back or from one side to the other. Getting a natural result in the temple depends largely on keeping the angle of the recipient sites very acute with the lateral slit blades and directing them in the proper direction, usually down and slightly rearward. Mike Beehner, M.D.

There are a number of factors to consider in deciding if one week is enough time before returning to work and having every person you bump into stare at your head and start asking questions about what happened. First of all, there's a big difference between how a patient looks the day (or two days after) a transplant versus how he looks at 7-9 days. Most FU scabs have fallen off by a week, but there can be persistent short stubby hairs just sitting in place, or, as has been already mentioned, a slight "pinkness" to the various sites. Most of the time these short hairs just sit there and eventually fall out or later get replaced by the growing hairs at 3 months or so. They can be shaved down if need be, and also, makeup that matches your skin tone can be dabbed on the pink sites to hide that. The issue of recipient sites looking pink is a very individual thing and varies from one patient to another. I find that the vast majority of men don't have this after a couple of weeks, but some of the fair-skinned men do keep it for a few months and it does eventually fade, especially once the hair starts growing out at 3-6 months. A major factor is whether or not you have some pre-existing native hair on top which can be swept sideways or forward to help camouflage things. If so, then a little hair spray helps to hold it in position during the day. If a person has a job in which a hat can be worn, then they can return to work in a couple of days, as long as they are not required to wear a hard hat (I wait a week on those and helmets). The Graftcyte kit can work wonders for many men and have them looking "office-worthy" 7-9 days later. I mention the 9 day interim, because the ideal is to have the procedure on Friday and then return a week from that coming Monday, which gives you two extra days. The most important thing to consider in the above question is how private and paranoid the patient is that another human being on earth will discover that they had a hair transplant procedure. At 9 days I find that most normal people look fine and can return, but certainly someone with a very discerning eye will slightly notice that something has happened, but it is not an appearance that will scare women and children. Rather, it's a subtle thing at the hairline edge mostly. If a man is a shiny bald Norwood VI, then certainly he's standing out in the middle of the field naked and probably does need two weeks to heal up enough that things aren't that noticeable. Each case has to be individualized. The other situation is the man who wears a hairpiece, in whom it is best not to wear the piece for a full week after surgery, and then minimize its use thereafter and be sure it is attached by clips which are moved periodically, so they tug at different hairs. Mike Beehner, M.D.

This 43 y/o male had approximately 500 FU grafts placed in each side temple area over three sessions, along with transplanting the front half of his scalp on top. He came by for a visit today and his recent photos are shown in the "after" views displayed here. There is a 7 year time span from the very beginning "before" shots up till now, when the "after" shots were taken. Mike Beehner, M.D.

There are a couple of things that pertain to this issue: As "Future HT Doc" pointed out, if there is more than 5% miniaturization or even a larger amount, then doing a transplant on that individual may not be a great idea, unless the patient understands that the gains may be only for 5-10 years. In our practice, if the assistants are dissecting out FU grafts and come upon a single miniaturized hair, sitting all by itself as a 1-hair FU, we do NOT make an FU graft out of that but throw it aside. I don't feel that the injury of a recipient incision is worth the tradeoff of putting a follicle/hair in there that is unlikely to end up being a full terminal hair. On the other hand, if that same apparently miniaturized follicle is part of a two-hair FU bundle and the other is a non-miniaturized follicle/hair, then we definitely try to include the weaker appearing follicle, on the chance that it might contribute something or also - importantly - on the hope that it may be a hair in the very early anagen growth phase, which can sometimes be difficult to tell. In general, I find it rare to find miniaturized hairs in the center of the 'good" donor hair; it is an issue that much more frequently applies to my female patients, most of whom have some small degree of miniaturization. It's then a judgement call as to whether they are a good candidate, and depending on the degree of miniaturization, then I lower the expectations in describing the possible benefits of HT. Mike Beehner, M.D.

I don't think that distinction would matter at all. I am not aware of any experience by any hair transplant doctors specifically with men who started wearing a hairpiece at the time of or shortly after their first hair transplant procedure. All of the experience I am talking about, from my own practice and from that of several very experienced and well-regarded surgeons, was from patients who had been wearing a hairpiece for several months or years before their procedure. This has not been scientifically studied, but is a clear impression by myself and others. Most of us think this is probably due to some sort of "shuffling" mechanical effect that the hairpiece has on the newly placed grafts during the days and weeks immediately following the procedure. One other situation I have often encountered is the man who wants the front hairline area transplanted and then intends to wear a hairpiece behind it. Often, this person has been wearing a full-cover hairpiece prior to the procedure. I have to emphasize that 75-80% of my hairpiece-wearing HT patients have wonderful, normal appearing growth. Those are still pretty good odds, and I do feel that simply not wearing the hairpiece during the week after surgery and then minimizing its use at home whenever possible helps those odds for good growth along a lot. Mike Beehner, M.D.

Your situation is a little different from the usual one we encounter. It sounds like you are going to go out and get a hairpiece to help cover what you view as the obvious signs on your head that you had a HT. I am assuming you must have a fair amount of native hair still on the top of your head, since otherwise suddenly presenting to your friends and co-workers with a new hairpiece on would seem to me a much more jarring change than that of recent HT grafts. For one thing, if you have the luxury of taking three weeks off (most of my HT patients go back to work after one week), I don't know why you would even want to bother with the hairpiece, as you could wear a baseball cap out in public in the meantime. After 2 or 3 weeks, most HT's are undetectable and most of the small hair stubs and scabs have all fallen off. Then the hair comes in very gradually, with different hairs emerging at all different times over a few month period. If you wanted to prepare your family or friends for a little more dense appearance on top, then possibly adding a little Dermmatch prior to the hair emerging might be a good strategy. There is a certain percentage of hairpiece wearers for whom the transplants just don't grow as well as in non-hairpiece wearing patients, I would say around 25% of them. It helps to have them not wear the piece the first week and keep it off as much as possible while around the home. Also, in my opinion the hairpiece must be a clip-on type, and if worn over several months, it helps to rotate the position of the clips to avoid small areas of circular tractiion alopecia. Mike Beehner, M.D.

This 25 y/o female 11 months ago had a single first hair transplant session of 1730 FU grafts placed in the front half of her scalp. Her FU's distributed into 20% 1-hair grafts, 60% 2-hair grafts, and 20% 3-hair grafts (high for a female) and totalled 3633 hairs. Because she parted from the left side, a small oval area was designated for extra-dense packing compared to the rest of the area transplanted. The photos will be displayed with all of the "before's" shown first and then followed by all of the "after's." The first 4 photos in the top row are "before's. In the after photos, some flecks of seborrheic dandruff will be noted, which can be secondary to cosmetic products being used, and occasionally can be stirred up a little during the months after a transplant if the patient previously had seborrheic dermatitis, which wasn't the case here. Mike Beehner, M.D.

One other thought occurred to me on what would give a viewer the impression you described of a bunch of hairs coming out of a small space on the head, and that is if the graft was "pitted," which looks like the hairs are coming out a dark hole, and they usually look compressed. This was commonly seen 15-20 years ago when some clinics had their techs put the grafts in a little deeper to make sure they wouldn't fall out, or when roundish grafts were put in slits and fit better when the top of the graft was tucked down under the slit, thus leading to the "pitted" look. I will attach two photos, one which shows pitting close-up and the other from a distance in a crown that we fixed (not done by us, sorry!) in which the pitting is evident especially over on the right side. Mike Beehner, M.D.

Dear RC West, First of all, by definition, a single hair follicle can only have one hair growing out from it. It is impossible for two hairs to come off of the same follicle. Obviously, it is hard for you to know the number of follicles under any given group of hairs, since the follicle resides completely under the skin. It sounds like what you have seen may have resulted from "pairing" of FU grafts. This means that, for example, your doctor may have inserted a two-hair FU into a small slit opening, and then later on had some extra 1-hair or 2-hair grafts and slipped one of them in along side the previously placed 2-hair graft in the same slit. Many doctors do this in the front-central area to increase density somewhat. However, when you look at one of these, it can look like an awfully lot of hairs coming from a tiny opening all together. In contrast, when we in our clinic place a DFU (double follicular unit graft), the slit is slightly longer and the normal spacing between the two FU's within the DFU are maintained and it looks pretty darn normal. In contrast, when two FU's are "paired", they can look concentrated in density, and it especially looks bad if it is done anywhere near the front hairline. Mike Beehner, M.D.

Shankar, The other commentator is right; a scar doesn't ordinarily get slimmer over time, although at 70 days post-op, I think it almost certainly is as wide as it's going to be. What does happen over that first year though is that the COLOR of the scar goes from a pinkish color to a white one similar to the surrounding scalp, so that it is much less noticeable. Because of the huge variance from one patient to the next as to the elasticity of the scalp, I would say your doctor went out on a limb promising you a 1mm or less wide donor scar. The 1cm width he chose for your donor scar is certainly a conservative width, and he certainly wasn't pushing the envelope there. In my own practice, first time transplant patients end up with a 1mm or less scar probably 80% of the time, but some of the others end up with 1.5, 2.0, or rarely 3mm. This latter happens in those with "hyper-elasticity" of the scalp. When we inject the tumescent fluid into the donor area prior to making the cut, we can often tell who actually is hyperelastic and then plan the excision and post-op care to try and help the scar end up as narrow as possible. Ways to do this are the following: Leave the sutures in longer (14-18 days, instead of 8-10) Not take quite as wide of a strip Keep a small section of scalp intact just behind the ear, so that the donor strip doesn't go all the way through this area, but rather is divided into a straight strip from the back wall and two (if needed) strips from the sides. In the first couple of months post-op, have the patient avoid doing activities that accentuate flexion of the neck down onto the chest, such as sit-ups, laying in bed reading at night with the head propped up on 2-3 pillows or cushions. I am also one of those who believe trichophytic closures are only indicated for those who are having their LAST transplant procedure. I will make an exception if I think a patient has a lot of laxity and doesn't intend to have another surgery for quite a few years, in order to maximize the cosmetic appearance of the donor scar in the ensuing years. In general transplant patients have to be told that they should expect to wear their hair at least 1/2 inch in length to cover the typical donor scar of 2-3 sessions, as most patients have. If they are not willing to do that, or still want to preserve the possibility of shaving their head, then they should look into a non-surgical hairpiece or possibly FUE, if their project isn't too large. If they are heading toward a typical Norwood VI degree of baldness later in life, then I am quite sure that the cosmetic deformity of that many FU's using FUE will give a "moth-eaten" appearance just as unsightly with close shaving as the worst donor scar. So, in summary, my prediction for you is that in around 10 months your scar will look just fine, but won't be any slimmer, and shouldn't be wider. Mike Beehner, M.D.

This 47 y/o male presented several years ago, when our sessions were considerably smaller than the ones we do currently; the "after" photos were taken more recently and show the results of 3 sessions totalling 3630 grafts (2435 FU's and 1195 MFU grafts) A total of 10,851 hairs were moved. His results are more impressive than the average patient receiving this many grafts because of the coarseness of his hair. Mike Beehner, M.D.

This is the second of two 49 y/o identical twins who came for dense-packed frontal and temple area transplant sessions 2 1/2 weeks apart. This second of the twins had his hairline and temple margin placed quite a bit back from his brother's, and had a total of 1510 FU's placed with a total hair count of 2969. We elected not to use the methylene blue dye in his surgery. He also will return in one year for re-evaluation regarding the need to do a second pass surgery to fill in for more density, which is likely. Mike Beehner, M.D.

This patient is a 49 y/o identical twin, both of whom came in to the office within the same month for consultations and had their first surgeries 2 1/2 weeks apart. This member of the twins pushed very hard for an aggressive, forward placement of his hairline and anterior moving up of the side temple areas also. We placed 2657 hairs in the front hairline and temple areas, and used a methylene blue dye to better see the sites. This dye completely disappears by the third day in most patients. These photos are taken the morning after the surgery at the time of the hairwash, and the dye was 50% less prominent than immediately after surgery. If he were younger (20's or 30's), I would not have agreed to fill in this far forward, because I would be a little afraid of what might happen in the future, but because of his age at 49, I felt comfortable doing this. He will return in one year, at which time we will see if a second touch-up is needed, which I told him is 75% likely. Occasionaly we hit a "home run" with one session when the hair is sufficiently coarse and there are lots of 2-hair and 3-hair FU's in the mix. The photos of his brother will follow in a separate post. Mike Beehner, M.D.

This 51 y/o male first presented over 10 years ago and had three large (at least they were considered "large" at the time) procedures over the years, with the emphasis on filling in the front 2/3rd area of balding. Some FU grafts were also placed in the rear vertex for a light, natural fill-in. He previously wore a hairpiece and totally got rid of it after his last procedure grew in. A total of 4737 grafts (3848 FU's and 889 DFU's) were placed for a total of 12, 729 hairs. Mike Beehner, M.D.

This 39 y/o male presented three years ago for transplantation of the front half of the balding scalp. He had two sessions totalling 2478 grafts, with 2243 of them FU grafts and 235 MFU grafts (all placed at the first session). Total number of hairs the patient received was 5638. He was happy with the density from the two sessions and didn't feel he needed more work at the present time. Mike Beehner, M.D.

This 44 y/o male presented a few years ago for his first HT session and returns now a year after his second session for a final "touch up" session of 2000 FU grafts. In total the "after" photos here show him having received 7659 hairs from 2467 FU's and 452 DFU's. He presented with a very high forehead and thinning, tufty front hairline which has been strengthened. Mike Beehner, M.D.

I was very grateful that the patient was able to be seen by Dr. Limmer to check on his post-operative situation. Dr. Limmer communicated his clinical findings to me and I thought it would be better if I put on the record here what they were, so that anyone judging me based on this case would have a fair picture. Our reputation is the most valuable thing we have. Most hair surgeons, including myself, try to honestly spell out the risks of surgery to each patient before getting their consent to go ahead. We do the best we can and then stick with the patient through any post-op problems, which fortunately in hair transplant surgery are very few and far between. We also learn from each of our cases. My "take-home" from this particular experience will probably be that I will not do FUE on patients that live far away and can't drive to see me, should any problems arise. Returning to Dr. Limmer's evaluation, in his report to me,he stated that he found no scarring and felt that everything was healing fine. There was one tiny pustule (a small yellowish bump on the skin)which drained without requiring any incision or cut, and there were 2 small scales of skin which fell off with being slightly touched. In the areas where the patient complained of some "aching", Dr. Limmer could not see nor feel with his hands any problem. I hope this closes the book on this case history, but I just wanted to have the record include these findings It's a pretty helpless feeling as a doctor when you can't personally evaluate a problem one of your patients is having and take care of it. My fervent hopes are that everything settles down for him and that the growth of the 75 1-hair grafts in the scarred area of his eyebrow grow in nicely and with regular trimming give him a normal appearance and a better feeling about himself. I know that this is his hope also. Mike Beehner, M.D.

This 47 y/o male presented first 11 years ago and spread out three sessions in the first 4 years, totalling 2972 grafts (1037 MFU's and 1935 FU's) making up 8377 hairs. His hair was of very fine caliber without a lot of body mass to it. He presents now 7 years after his last session seeking a "touch-up" for increased density and more FU's into the crown. A session of 2200 FU's is planned for next week.

This 48 y/o female with a long history of progressively thinning hair presented a few months ago. 1558 FU's were placed in lateral slit incision sites made with a 0.8mm, 0.9mm, and 1.0mm size custom-made blades. A weak methylene blue solution was applied over the sites after they were made to assist in easily finding them for both placement and to make sure there weren't spaces that were missed in the site creation. Her FU's were 20% 1-hair grafts, 50% 2-hair FU's, and 30% 3-hair FU's, which is unusual for a typical female transplant patient. A total of 3584 hairs were moved. 140 2-hair FU's were packed in very densely in a small circular front-central area by myself, using the stick-and-place method. She will return a year from now for evaluation and hopefully a second procedure. Mike Beehner, M.D.

Sidat, We try to have a minimum of 10-12 months between the first and second session,12 if there is a fair amount of native hair still on top and 10 if there isn't. The reasons for waiting this long are as follows: 1) Most importantly, time for the vasculature (blood supply) of the scalp to return to normal after the previous surgery with its large number of micro-injuries. 2) Time for the donor area to become lax and loose again so that another donor strip can be taken and a narrow scar is still possible. 3) Time for the hair to grow out, so that in the second session there are no "direct hits" on any of the new grafts. 4) And lastly, time for the hair to grow out sufficiently that the patient feels confident the procedure works and is motivated enough to do it again. Hope that helps explain the time between. Mike Beehner, M.D.

Since this patient's interaction with me has been carried out in public view, I thought I would add a few comments to simply give my perspective on the case and what can be learned from it. The patient is a nice young man who approximately a year before his surgery with me was the victim of an assault which resulted in some scarring and missing hairs in the left eyebrow (see attached photo), which distressed him quite a bit. He sent me an e-mail in December of 2009, noting that he liked the quality of our eyebrow results, and, due to lack of financial resources, asked if I would do his eyebrow transplant work as a pro-bono case without charging for it. I agreed to do this and set aside one of my days off to do it on. The patient and I communicated back and forth as to how the hair would be harvested. I stated that all of the eyebrows I had done to date (nearly 150 cases) had been done with a strip harvest, as I felt the 1-hair grafts could be better dissected under the microscope than with FUE, and also we could leave the hairs long at around ?? inch, which has two advantages: It helps me see the slight curve to the hair that each person has, so that we could rotate the graft to conform to the 'flow' of the eyebrow contour and to hug the skin; Second, by leaving the hairs longer, I do a slight trim at the end of the case and, by seeing these long hairs in the mirror, the patient at the end of the case gets a good idea of what his eyebrows will look like later when the hairs finally grow out. The hairs we transplant obviously mostly shed and are replaced later by permanent hairs. Just a day or two before he flew out he indicated that he really wanted to preserve the option of keeping his hair very short and asked that I use FUE for harvesting. We have done around 80-100 cases of FUE, mostly for camouflaging donor scars and in chest hair harvesting when someone had no more obtainable scalp donor hair. During that 3-4 year experience doing FUE, we had never had even a minor complication. I use all 1-hair grafts for my eyebrows. From the photos he sent, I estimated 35 grafts might do the job, but at the time of surgery was able to fit in 75 grafts using a tiny 22g needle and a stick-and-place technique, hoping this number might allow for a single session accomplishing our mission. His occipital donor follicles/hairs were not easy to obtain with the FUE technique. I use the 3-step Harris method, using a sharp punch for the initial 1mm deep impression through the epidermis and dermis, and then the dull punch to strip away the deeper attachments, and then the 'plucking' of the follicle out with the forceps. As any experienced FUE surgeon will attest to, some patients are very easy to extract these grafts and in some it is very difficult. In the early days of FUE, Dr. Bill Rassman advocated doing what he termed the FOX test beforehand and ended up rejecting a fairly large proportion of patients as being FOX-negative and using strip on them instead. I haven't done such a test during consultations, as I felt it was a little 'invasive' from the perspective of the patient. On the day of this patient's surgery, I had already sedated him and felt committed to finishing the job with the FUE technique. A photo is attached showing a lower and slightly higher shaved occipital area in which I did the FUE. I targeted 1-hair bundles and made overall 132 holes to obtain the 75 grafts we used. We did the lower ridge first, which were difficult, and then went to the upper area, which was easier and resulted in a higher percentage yield. When performing FUE, there are 3 things that can happen. Either you pull out a nice FUE graft, or a thing called 'capping' occurs, in which during the forceps pluck, the very top of the graft, namely the epidermis and dermis along with the short hair, are pulled off, leaving the main body of the follicle intact in the skin, which will continue to grow and survive. The 3rd thing that can happen is that the whole graft can bury down in the hole. In most cases I try to retrieve this with a fine-tooth forceps when it occurs, but sometimes they are hard to find. Prior to this case I had never had an FUE patient have a reaction to any left-behind particles down in these holes. It is apparent from the patient's description that some reaction to some buried fragments of the follicle or hair has occurred. When doing a patient from long-distance, which constitutes nearly one-third of our practice, the one big disadvantage is that it is not easy for the patient to get in his car and come and visit if any small problem arises post-op. We are fortunate that for the most part hair transplantation surgery is virtually complication-free. I felt bad that I couldn't examine and put my fingers and eyeballs on this patient's donor area to assess the problem. The surgery was on January 11 of this year, and the patient and I have exchanged several phone calls and at least 20 e-mails reviewing what could be done. Very early, besides recommending hot packs and an antibiotic, which I called in, I emphasized the over-riding importance of having a physician with some surgical background examine him to make sure there was no abscess present which would require incision and drainage. The first physician he saw apparently didn't know what to think and did not appear to have much surgical background. The ER physician he saw was more helpful and assured him there was no abscess or infection present. Things seemed to be getting a little better, but then the patient remained alarmed, and at that point I personally called Dr. Arocha from Houston and asked if he would be willing to see the patient, and he graciously agreed. The patient was very grateful for this and said he would try to get down to see him in a couple of weeks. After several days, I then decided that the best course was for myself to see what was going on and I called the patient and told him I would cover the cost of travel and airfare to Albany for me to examine him in my office in Saratoga and do whatever needed to be done. He again was very grateful and said that due to pressing college study issues, he couldn't now, but we left off that we would talk in a week, and if things were not better, he would then decide between either coming to my office or seeing Dr. Arocha. As you can see, the doctor-patient relationship becomes very important when dealing with any post-operative problems. The lions share of my patients have a personal consultation in which I can better assess this aspect. Perhaps in this case the time of our intervening was too close to the emotional trauma of the attack he endured and which had a severe effect on his self-image. I remain confident that the eyebrow transplant we did will improve his looks. He is aware that he will have to trim those hairs the rest of his life and also that in at least half of our eyebrow patients, a second pass of grafts is necessary to achieve the final density, but I am optimistic that one session may be enough now. I remain supportive of the patient and will work with him to get him through this, regardless of what is needed on my part. Patients often ask me if we offer a 'guarantee', as one of your posters recently asked about, and I reply that we don't. I have found them gimmicky and impossible to prove in the past. But what we do promise each patient is that we will stick with them and make sure they are happy when their transplant journey is over. I am pretty sure that if you contacted all of the 2600 patients I have treated over the years, that 99% of them would attest this is true of our practice. Usually the doctor-patient relationship takes place between the doctor and the patient, but in this new era of the internet, I understand that some patients will want the support and input from others. I understand this, but it is a little difficult to get used to, and I hope to be better about it in the future. Thanks for listening. Mike Beehner, M.D.