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Michael Vories, MD

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Everything posted by Michael Vories, MD

  1. My understanding is that a licensed Physician Assistants (PA), can perform extractions if they are operating under a physician's oversight, but not a Registered Nurse (RN). I believe this goes back to the Scope of Practice guidelines for dermatology, where a PA can perform a punch biopsy under a physician's supervision.
  2. In September 2019 the California Medical Board issued a position statement that unlicensed medial assistants cannot perform FUE extractions. This most likely will be adopted by different medical boards in the US, and slowly this scourge of non-physicians performing surgery will be eradicated. Because FUE grafts are fragile compared to FUT grafts, we use hair implanters to place grafts in a "stick and place" method, which also requires the physician to perform the graft placement as well. My hope is that more physicians will go back to realizing their place is in the surgery suite.
  3. I believe this is likely to be true. Depending on the thickness of the punch wall, there can be a considerable difference between the internal and external diameter of the punch. The measurement of the punches we use is based on the external diameter, which is what will determine the actual wound size.
  4. We have been seeing patients who have had a FUE procedure performed with the ARTAS robotic system in which the punches used seem quite different in size from the ones we use, even though they are being told they are the same size. This patient had a 2000 graft ARTAS procedure about two years ago, in which he was told the occipital harvesting was performed using a 0.90 mm punch. We performed a second 2000 graft surgery one year ago using a sharp punch system, also with a 0.90 mm punch. He came in this past week for a smaller procedure and that is when the photo was taken after his hair was clipped. The extractions in the upper half of the occiput was performed two years ago using the ARTAS machine, and the lower half was using our sharp punches one year ago. We did not perform any extractions in the upper half for fear of over-harvesting. As we all know, FUE is not a non-scarring procedure, but the scarring is definitely related to the punch size, and keep in mind that all punches are not calibrated equally.
  5. I believe the greatest advance from a surgical perspective to hair transplant surgery is not the development of FUE, but rather the increasing use of implanter pens for graft placement. This allows for no trauma to the dermal papilla (bulb of the graft), and gives consistent and reliable growth.
  6. I understand your concern, but keep in mind that temporary shock loss is going through the same hair cycling as the transplanted hair. This means that when your transplanted hair begins to grow is when the donor area shocked out hair begins to grow in.
  7. Larger punches such as 0.95 mm and 1.0 mm are more likely to cause temporary shock loss.
  8. This 48 year old male came into the clinic today for his 6 month follow up after receiving 4000 FUE grafts in a two consecutive day session. 1500 grafts were focused in the crown, and the remaining 2500 grafts in the midscale, frontal forelock, and hairline. He is not taking finasteride as his hair loss has been stable for over 10 years.
  9. Our practice is a little unusual in that I like to do all of the extractions and placement myself. My assistant counts and collates the grafts as they are coming out, and during graft placement is loading the implanter pens as I do the insertion. For most cases I only use one assistant. For this reason we can only perform one procedure per day.
  10. Yes it is difficult when patients with advanced hair loss, since most look best with very short hair. On exam he was a Norwood 6.
  11. This patient came in for his 6 month follow up after receiving 4000 FUE grafts over a two consecutive day session. 2500 grafts were placed in the frontal forelock/hairline, and 1500 grafts were placed in the midscalp. Patients with fine hair and extensive hair loss often present challenges with coverage, but with this patient the lack of contrast between the skin color and hair color helps with the illusion of density. All grafts were harvested and placed by the physician. Full facial images are shown with the consent of the patient.
  12. Hair transplants are already quite expensive without adding all of this stuff. We give patients (do not charge extra) that includes a saline spray, head and shoulders shampoo, and a surgical sponge for sponge washing the first week post-op. As mentioned generic finasteride is dirt cheap, and minoxidil is relatively inexpensive as well. Clinics that charge extra for additional products are taking advantage of patients in a vulnerable position to add to the bottom line without any evidence that it improves the results of the procedure.
  13. We need to keep in mind that the patient is a vulnerable state, and should not be asked to make decisions once the procedure has begun. On the morning of the procedure I explain that if we are short grafts, then the patient is refunded the difference, and we have extra grafts, they are placed without charge.
  14. This is not a before/after. This is simply a patient we performed a two day, 5000 FUE graft case last week. The reason I am presenting this is that this patient previously went to a local plastic surgeon who had just obtained an ARTAS machine, and is marketing heavily here in the Charleston, SC area. During his consultation with the ARTAS clinic, he indicated he wanted coverage both in the crown and frontal area, and was told by the consultant (not the plastic surgeon), that complete coverage could be obtained with 1500 grafts. Looking online afterwards, he realized this was an absurd quote, and ended up coming to us. The point is for prospective patients to do their research before (and after) a consultation because there is some inaccurate information being given out, and just because someone has a machine does not make them qualified to perform the procedure.
  15. There is a wide variability in total donor capacity. However, for most patients with no prior procedure with what we consider “good” donor (around 80 follicular units/cm2) we can safely extract between 7000-9000 FUE grafts.
  16. From the photos 3500-4000 grafts seem like overkill. I would estimate from them that 2000 grafts would be plenty to fill in the apex areas and hairline.
  17. This out-of-town patient sent in these photos for his 6 month follow up after receiving 2500 FUE grafts to his frontal forelock and hairline. Grafts were manually harvested with a 0.85 mm sharp punch, and placed with Hans Lion Implanters. All grafts were harvested and placed by Dr. Vories.
  18. In the frontal area we placed grafts at 40 grafts/cm2. In the midscalp and crown this was reduced to 30 grafts/cm2. We use the Cole Instruments sharp punch system for tissue extraction.
  19. This patient came in yesterday for his 6 month follow up after receiving 4000 FUE grafts over a two consecutive day session. 2000 grafts were placed in his crown/midscalp, and the remaining 2000 grafts were placed in his hairline/frontal forelock. Due to stable hair loss pattern he is not taking finasteride. All grafts were harvested and placed by the physician.
  20. This patient came in yesterday for his one year follow up after receiving 2500 FUE grafts to his frontal forelock/hairline. He now is scheduling a second procedure to address his crown/vertex. A 0.85 mm sharp punch was used for extractions, and grafts were placed using Hans Lion Implanters. All grafts were harvested and placed by the physician.
  21. Dr. Lorenzo was the reason I began using Hans Lion Implanter pens for graft placement. I use the Cole Instruments motorized sharp punch system, and a 0.90 mm punch was used for this patient's extractions.
  22. This 62 year old patient came into our clinic this week one year after receiving 2500 FUE grafts to the frontal forelock and hairline. He is scheduled for a second procedure for his crown this year. He is not taking finasteride secondary to stable hair loss. A 0.85 mm sharp punch was used for harvesting, and Hans Lion Implanter Pens used for graft placement. All grafts harvested and placed by the physician.
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