PupDaddy

Dr. Dorin of True & Dorin does some of the finest temple work I've seen.

Just as clarifying info to Zizou88's post, my understanding is that Dr. Konior is assisted in PG (placing grafts) by (at least) his lead technician. In other words, he is "involved" in that stage of the FUE procedure as well but his technician(s) also place(s) grafts in the recipient sites (which he makes). At least that is my understanding.

gorgeous! largest FUE case I've seen from Dr. Dorin, too.

Looks to me like different technicians implanted the left and right sides of your hairline and/or that the quality of the grafts differed as between the two sides. I think you could use a small session touchup of the left side of your frontal hairline. Otherwise, your transplant looks great.

Can I let you know in a few minutes?

Gasthoerer, I dont' contend that one type of Category A tool is superior to another type of Category A tool (I wouldn't know), or that Category B tools are "superior" to Category A tools or vice versa. Category A tools and Category B tools have different purposes--apples and oranges. I'm only saying that I favor the use of Category B tools for insertion of grafts into premade recipient sites over forceps-only insertion of grafts into premade recipient sites. If Dr. De Frietas uses true implanter pens for his hairline work that could help explain why he isn't on my personal "tops" list of hairline docs, although I admit I haven't studied a lot of his recent work. Timely and interesting topic.

We should make a distinction between (a) implanter tools that both cut the recipient site and implant the graft into that site, versus (b) implanter tools for inserting grafts into recipient sites that have already been made using a custom cut blade or needle. The critical distinction is that Category A tools are used by the surgeon (or technician at some clinics) to simultaneously make a recipient incision and plunge a graft into it, whereas Category B tools are used by technicians only to seat grants into recipient sites that the surgeon has already made. Category A tools include Choi and Lions type pens, as used by Lorenzo, Vories, and others. Category B tools include Erdogan's KEEP tool and Yaman's implantation tool. Category B tools essentially hold the walls of the pre-made recipient site open and form a channel for grafts to be fed through. Forceps are used in conjunction with the KEEP tool (a Category B tool), but only after the graft has been loaded through the side of the tool’s hollow tube using a sort of swiping-rotational movement off the back of the hand and only to then finish seating the graft into the recipient site. Yaman's implantation tool, also a Category B tool, is similar. It looks like a Category A implanter pen but the point of the hollow needle is blunted and isn’t used to cut a recipient site. Instead of using forceps to guide the graft the remaining way down the hollow metal tube into the recipient site, the technician uses the tool’s plunger to perform this task. Both these tools purport to reduce trauma to grafts that can result from gripping them at the "meat" between forceps and "cramming" them into tiny recipient sites--trauma that can be exacerbated by fatigue and by recipient sites starting to close up after some time. Some ht docs have employed a combination of Category A and B tools for FUE transplants, favoring blade or needle-made recipient sites for hairline work that are then filled using Category B tools (e.g. KEEP, Yaman) and using Category A tools to both make recipient sites and seat grafts behind the hairline zone. MY SUBJECTIVE, PERSONAL VIEW: I strongly favor ht surgeons and their teams using Category B type tools to reduce graft trauma during the implantation process. I am solidly against the use of Category A type tools for hairline and temple work. Based on viewing hundreds if not thousands of photos and videos, I don't see the consistent cosmetic refinement of hairline work and frontal temple work performed by the top surgeons using Category A type implanter pens (yes, I include Dr. Lorenzo and his spawn) that is achieved by top surgeons who make recipient sites using custom blades or needles. I personally think that graft survival and growth rates of FUE will be significantly enhanced, as will their consistency, by the widespread adoption of Category B implantation tools in the hands of well-trained technicians, everything else being equal. Excellent topic, Squidward! I hope you'll forgive my pontification.

Thank you for that clarification, Dr. Yaman. We are seeing real progress in FUE protocol and cosmetic results with the advent of newer, well thought-out motorized systems with better control and better designed punches, as well as graft embedding tools such as yours and Dr. Erdogan's. Keep up the good work!

Dr. Yaman, Am I correct that your new implanter device is for seating/embedding FUE grafts into PRE-MADE recipient site incisions? In other words, whereas traditional implanter pens (Choi, Lions, etc.) are designed both to cut a recipient incision and implant a graft into that incision, your tool is used only for the second part of the process, i.e. to seat/implant a graft in a recipient site that the surgeon has already made using a custom cut blade or needle? In that sense, this tool is used similarly to Dr. Erdogan's KEEP embedder, for example, yes? It is a tool used by the tranplant surgeon's technicians NOT to make recipient incisions but rather to seat FUE grafts into the doctor-made recipient incisions with less trauma to these delicate grafts that can occur with techs using only forceps to "push" or "cram" a graft into a recipient incision. Is that right? I personally haven't seen the same degree of hairline work refinement from docs and clinics using traditional implanter pens, but I see FUE graft embedding tools like yours and Dr. Erdogan's (if I am understanding your tool correctly) as an important advancement in FUE protocol.

Beautiful temple work!

Trix, I think you might be asking why some surgeons DRAW hairlines with squiggles whereas others do not. It seems just to be a matter of personal preference. Just because a particular surgeon doesn't DRAW squiggles (micro and macro irregularities) along the planned hairline doesn't mean that the surgeon won't MAKE them when he makes the graft incisions. Some ht surgeons choose to pre-draw the irregularities and more or less follow them, some don't, choosing to do things a bit more free-style/free-hand. That said, some ht surgeons generally seem to favor a lesser DEGREE of irregularity along the hairline than others, and vice versa. (For example, I would put Dr. Erdogan in the first camp.) Other docs routinely employ a pattern of tiny "spokes" or "triangles" extending from the hairline at regular intervals. Others favor more irregular zigs and zags and of varying length. Others still pretty much follow the line but insert randomized single hair "softeners" along it. This really is where the artistry of creating and transplanting a hairline comes in and is why you can often tell one doc's work from another's once you get to know their style. But whether or not the surgeon DRAWS the macro and micro irregularities into the pre-op hairLINE doesn't seem to indicate anything one way or the other from what I have observed.

I recall Dr. Konior posting a case here of a patient who wanted just a new hairline transplanted in front of his hair system. I don't recall whether any work was needed or done to the patient's temples or temple points, though.

Ingenious! Looks to combine the benefits of forceps placement into custom blade/needle recipient sites with the benefits of pen implanters, without the shortcomings of either method.

dude85, Precisely as Spanker just said: DO NO RETURN TO THAT DOCTOR. He inexplicably populated your temples and frontal hairline with 2 and 3-hair grafts, which is a huge no-no. Go see a top hairline doc (e.g., Dr. Konior, Dr. Gabel, Dr. Diep, Dr. Cooley, Dr. Shapiro, etc.) to assess your situation. Like Spanker said, there are several possible approaches to fixing this: (a) camouflaging the pluggy work by transplanting lots of newly-exctracted 1-hair grafts in front of, and between the 2 and 3-hair grafts, (b) punching out some or all of the 2 and 3-hair grafts and replacing them either with newly-extracted 1-hair grafts or with single hair grafts created by dissecting the punched out multi-hair grafts into 1-hair grafts, © electrolysis to "kill" the 2 and 3-hair grafts (as an alternative to punching them out and repurposing them) followed by transplantation of newly-harvested single-hair grafts, or (d) some combination of the above. Get thee to an elite hair restoration surgeon with an impeccable record for hairline work and hairline repair work.

Gorgeous!

harry, The page you mentioned on Dr. Konior's site explains that the stick-and-place technique means making a slit and then immediately filling that slit with a graft vs. pre-making lots of slits and then filling them with grafts. My understanding is that Dr. Konior uses custom cut blades to make recipient slits, whether he is doing the stick-and-place technique or is making pre-made slits. The difference, as I understand it, is that stick-and-place allows for using smaller blades to make smaller recipient slits because immediate placement of a graft into the slit prevents the slit/site from closing up. Smaller insult can be beneficial when transplanting amongst existing hair. Recipient slits can be oriented laterally with either technique. Stick-and-place Technique - Chicago, Gold Coast, Milwaukee, Oakbrook That's how I understand it, anyway.

I don't think people are appreciating just how good this is. Only 1,600 grafts in the frontal third, undetectable as a transplant, utterly natural hairline that provides excellent facial framing, and even with the patient having applied a heavy dose of mouse or gel to his hair, the transplanted area appears to match the density of the patient's surrounding native hair. Beautiful work. Dr. K: What tool(s) did you use for the extractions?

I stopped reading this poster's critique of Dr. Wesley right after he criticized him for not using a Neograft machine.

Congrats, jkm3! I missed your first thread. Glad I spotted this one. I really like the hairline design, layout, and execution that Dr. Diep did for you this go around. Just the right amount of irregularity, IMO. Should turn out great. The first picture of your collection (the one taken from below looking up at your hairline) is illuminating, especially comparing it to the 1-year post op photos that were taken with flash and before you discontinued Minoxidil. I can see why you would want additional density. Happy growing!

Looks great, Dr. P! Can you please tell us why you opt to divide FUE transplants of this size into two procedures? Thanks.

I don't read that sentence of Ezel's critique as saying that Dr. Feriduni didn't make all the graft recipient incisions. (Ezel?) I would be surprised to learn otherwise, especially considering that according to Dr. Feriduni's profile he uses custom cut blades for making graft recipient incisions. As I said, to my knowledge, Dr. Doganay is the only HRN-recommended physician found to have been delegating recipient site incision-making to nurses or technicians (non-physicians).

The problem is that you are conflating "implanting" with "incision-making." They are distinct tasks with distinct meanings, depending on the tool used to make the recipient incisions. EVERY HT PHYSICIAN RECOMMENDED BY THIS SITE MAKES EACH AND EVERY GRAFT RECIPIENT INCISION HIMSELF OR HERSELF. THEY MAKE 100% OF THESE INCISIONS, 100% OF THE TIME -- except, we recently learned, for Dr. Doganay, who allows technicians or nurses to make a third or more of the recipient incisions. One of three tools is used to cut graft recipient incisions for hair transplantation: custom cut blades, needles, or implanter pens. Most ht surgeons recommended on this site use custom cut blades to make the graft recipient incisions. Two (Rahal and Diep) use needles to make them. When custom cut blades or needles are used to cut the graft recipient sites, "implantation" refers merely to the route task of following behind the surgeon and placing (putting/seating/inserting/depositing) grafts into these recipient sites. Ordinarily this task is performed by technicians, using forceps. Under this protocol, "implantation" means merely placing/seating/inserting/putting/depositing grafts into recipient sites (incisions) made by the surgeon. The term "implantation" takes on a different meaning, however, when implanter pens are used. An implanter pen is a dual-function tool. It is used both to cut the recipient site AND to deposit (seat/place/insert) a graft into that site. It consists of a hollow needle with a plunger mechanism into which a graft is loaded. The needle is inserted into the scalp (the incision-making part) and the plunger is then pushed to eject the graft into the recipient site (the seating part). Thus, in the case of implanter pens, the term "implantation" refers not only to placing a graft into a recipient site but also to cutting that recipient site in the first instance. Besides Dr. Doganay, Dr. Vories is the only ht physicians presently recommended on this site that uses implanter pens. Unlike Dr. Doganay, however, Dr. Vories does all the "implantations" (cutting recipient sites + injecting the graft into the site) himself, as he should. The tool used to make the recipient incisions under this protocol is the needle of the implanter pen rather than custom cut blades or stand-alone surgical needles, but it the same cosmetically critical, surgical task of recipient site incision-making nonetheless. Technicians load the pens with grafts -- an appropriate task for technicians -- but only Dr. Vories actually uses the pens to pierce the patient's scalp, make recipient incisions and deposit the grafts. I hope that clears things up and explains why it is alarming and disconcerting to some members to learn that Dr. Doganay has been allowing his technicians to wield implanter pens, make recipient incisions, and, essentially, perform hair restoration surgery.

There is nothing "subjective" about Dr. Doganay's admission, posted here through his own online representative, that for paleo's case Dr. Doganay delegated more than a third of the recipient area incision-making to one of his techs. The doctor's rep confirmed that Dr. Doganay only made 65% of the recipient area incisions, leaving the rest to a non-physician technician or nurse. That point is an established, objective fact. Here is another objective fact: No coalition or recommended physician allows non-physicians to cut graft recipient incisions in the patient's scalp. Nor should they ever. That is a bright line that isn't crossed by reputable ht surgeons leading reputable ht clinics. Cutting the graft recipient incisions not only is plainly surgery, it (along with hairline design) is the heart and soul of the artistry of hair restoration surgery. Assuming that viable grafts have been harvested and properly stored, the location/placement, density (incisions per cm2), depth, angle, direction, execution, and je ne sais quoi of recipient incision-making determines the cosmetic result of hair restoration surgery and is what distinguishes one surgeon's transplant work from another. IMO, delegating this cosmetically critical surgical task, or any part of it, to the clinic's technicians betrays a "mill" mentality of volume and profit over regard for the patient or respect for the art of hair transplantation.

gorgeous hairline work by Dr. Bisanga!

Really top-notch repair work here by Dr. Feller, for a patient whose hair characteristics and prior work made the hairline work a real challenge. I'm guessing for this case that Dr. Feller elected to overwhelm and camouflage the old hairline work by implanting amongst it and in front of it, rather than punching out the old grafts and redistributing them?