Michael Vories, MD

One of three things have happened here. 

1. There was massive transection, where perhaps 3000 attempts were made, but only around 400 grafts were harvested intact and placed. This is the worst scenario, due to the wastage of limited donor hair. If this was the case, the procedure should been aborted early on when the high transection rate was noticed. We occasionally see this with Afro hair with a severe curl, but with straight hair we have never seen transection like this.

2. Only around 400 attempts were made and those grafts placed, which in our clinic would only take about an hour to an hour and a half to perform. Assuming the patient was in the clinic for the day, if this was the case it reflects a novice performing the procedure. Trying to pass off a 400 graft case as a 3000 graft case is just fraud.

3. 3000 extractions were performed, and only 400 of the grafts were placed, and the remaining 2600 grafts tossed into the trash. Actually this is just as bad as the first scenario. Again this is fraud.

Reputable hair transplant physicians recognize there is an honor system when it comes to graft counts. Most of us charge by the graft, so an accurate intact graft count is essential to keep trust with our patients. When that trust is violated as in this case, it is a black eye for the industry, and should never be tolerated. My inclination would be to contact the supervising medical licensing board. In the US, any signed complaint to a medical board must be investigated, and few complaints are as serious as outright lying to a patient. 

Actually if this patient went to a reputable clinic soon, with the grafts so spread out, there is little risk of damaging the previously transplanted grafts. It would need to be done within the next couple of weeks before the grafts begin to shed.

This patient came in this week for his 6 month follow up after receiving 2000 FUE grafts into his frontal forelock and hairline. He has a stable hair loss pattern over the last 10 years. Grafts were harvested with a 0.80 mm sharp punch, and grafts placed with Hans Lion Implanters. All grafts were harvested and placed by the physician.

This patient came in for diffuse thinning of the hairline and frontal forelock, and restoration of his crown area. 4000 FUE grafts were extracted and placed, with 2000 grafts focused on the frontal area, and 2000 grafts in the crown (vertex). Photos are at the one year post-op mark. All grafts were harvested and placed by the physician.

He is stable on finasteride for the past year.

This patient came in today for his 6 month follow-up after receiving 5000 FUE grafts over a two consecutive day period. 2500 grafts were placed in his crown/vertex, and 2500 grafts were placed in this frontal forelock. I expect his vertex will continue to improve over the next 6 months. All grafts were harvested and placed by the physician.

Based on his donor I would estimate another 2000 grafts or so for future procedures.

This patient came in for his 6 month follow up after receiving 4000 FUE grafts over a two consecutive day session. He is not taking finasteride due to side effects. All grafts were harvested and placed by the physician. All grafts were placed using Hans Lion Implanters.

I was curious and clicked on this website, and found two of our patients on their before and afters. I guess I need to have a talk with them.

His crown did have a good response to finasteride, and his hair is a little longer than in the before photos.

This patient came in recently for his one year follow up after receiving 2500 FUE grafts in his frontal forelock and hairline. He is scheduled for another 2000 grafts for his vertex and we should have that result in about a year.

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.

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.

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.

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.

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.

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.

Larger punches such as 0.95 mm and 1.0 mm are more likely to cause temporary shock loss.

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.

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.

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.

He is 38 years old.

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.

Actually we like the zinc in head and shoulders to help with healing.

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.