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Dr. David Josephitis

Certified Physician
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Everything posted by Dr. David Josephitis

  1. naveenram15, It is a big challenge for smokers after hair transplant surgery. While there have not been any studies done on hair surgery, we know from other general medical studies that smoking can and does hinder the healing process. One of the big issues right after transplantation is that the grafts have not yet established an adequate connection to the circulation. We try to do everything possible to improve the likelihood that grafts survive. (Grafts stay moist after surgery, they are placed as quickly as possible back into the scalp, ATP spray after surgery to increase oxygenation to the hair, etc). The issue with smoking and surgery is that there is a chance that it will affect the overall results. The fact is that occasionally after surgery the results are not as we expect. Usually, there is poorer overall result or there are thinner areas here and there. Smoking increases the chance that there can be a poor outcome. The chances are still good that a smoker with have a great outcome. Still, the chances are also slightly higher that if the patient has a bad outcome, it might be connected to smoking. At Shapiro Medical Group, we try to do everything to reduce the chance of a poor outcome. As mentioned before, we add many things to surgery to improve on this rate of success. The patient also plays an important part in increasing the chance of a great result. Stopping smoking or greatly reducing it is one of the things they can do. In reality, it is very difficult for a smoker to quit. For those patients, I recommend cutting down and/ or nicotine replacement. It looks like you did a great job of holding off for the first week. The longer you can hold off, the better. After that, within reason do your best to cut it down. Because of all you invested in your hair at this point, it may also be a great reason to quit! Good Luck.
  2. A scar revision is just the act of removing scar tissue safely. If one takes our scar in addition to hair, then there may be to much tension on the healing incision and it will scar again possibly worse. In the end, it is all about tension. You can only take out so wide of a piece of tissue. If you are only taking out scar, the chances of there being little tension on the incision and healing well is higher than if you took out the scar AND the additional width of tissue with hair. I recommend visiting with an experienced local physician who has experience with FUT. The recommended physicians on the site are an excellent place to start looking.
  3. During a scar revision, the focus is on removing the scar only. When we perform a hair transplant surgery using the strip method, we can not get the same improvement in the scar as if we took only the scar out. Occasionally we can improve on the scar an the same time as the hair transplant surgery. We call this transplant with scar revision. If you have a poor scar that you would like to improve and transplanting hair right now is not an issue, then the physician can focus soley on improving the scar with a revision (no hair transplanting) Physicans who routinely perform FUT (strip) surgery and have experience are usually good a these types of scar revisions. There can also be somewhat of an art to improving scars as well. Occasionally it may take 1-2 scar revisions with a poor scar to make improvement in it. Also, some patients may benefit from using FUE grafts (from the scalp or beard) to be placed in the scar. Finally, SMP (micro tattooing) can be done into the scar to help camouflage it with the surrounding scalp.
  4. hairsafelife, Welcome to the forum. It sounds from your post that you have normal male pattern alpecia. This is diagnosed, as you know, from the typical pattern that one sees on the top of the scalp. The donor area usually is not affected by this type of alopecia. DUPA (diffuse unpatterned alopecia) is a condition that results in diffuse thinning throughout the entire scalp including the donor region on the sides and back of the head. These patients are not good candidates for surgery. It is hard to determine how much hair you are losing from this area from your post. Remember that most people (even people without hair loss) lose 100-150 hairs on average per day. This is normal. These hair are going through the normal hair cycle. This hair is shed from all areas of the scalp, including the donor area. If you are concerned about your donor region, I recommend you visiting with a hair restoration surgeon to get an accurate assessment of your donor area and a potential plan for hair transplantation if you are interested in that as well.
  5. I think in order to know accurately how many grafts you need, it would be a good idea to visit with a hair transplant surgeon. The area of loss is not the only thing we look at when deciding how many grafts to use. We also look at age, future loss, family history, your own goals. Having said that, FUE is an excellent choice for this type of restoration. Your graft range ca be anywhere from 1200-1800 grafts. Also, occasionally people do additional surgeries on the same area to increase density. This is also something you might want to do. I hope this helps.
  6. Thanks for the ongoing interest in the study. We currently have 4 people in the study at various post op points. The first two are currently around the one year post op. I unfortunately can't reveal any of the actual data or photos at this time, as all of the data from all of the patients is not in yet. We want to make sure we are careful in our assessments before coming to any conclusions. Having said that, preliminary results have been very promising! At this point, there is very little to no differences in the results of the recipient in the FUT vs FUE side. The growth, yield, and density visually appears to be the same. This is from photography alone. As I mentioned, hair counts have not yet been fully counted. This is good news though for patients debating whether to go with the FUT or FUE. We are still looking for a couple more patients to enroll in the study to further bolster our results. Thanks.
  7. It appears you have the option of doing another FUT of an FUE this time around. As other have suggested you could do another FUT because you already have a linear scar. You noted that you would prefer a shorter post operative healing period and that is why you are leaning towards FUE. That is not a problem. The only issue you may run into is that it may be challenging to hide the linear scar in the short term while your has has been shaved short for the FUE extractions. You might want to consider doing the "non-shaven" FUE. This way you could maintain your current hairstyle and still get the FUE. Dr. Harris in Colorado has been doing this for a while. We are also doing it here at Shapiro Medical Group. There might also be physician near you as well. The density of 70 should not be a problem unless the donor area becomes very depleted. A physician can evaluate that for you. Also, if you ever want to do an FUT later, the FUE now should not hinder that procedure. Again, an exam by a hair physician would be your best bet.
  8. hairman22, It appears you have very early thinning in the vertex at this point. You may be correct that you also have a little shock loss, although it is less likely because the last transplant was in the frontal region. Some surgeons, like myself, do not like to do any work in the vertex in young patients.(<35 yoa) The reason is that we are not sure how your hairloss will progress. Typically starting to lose hair in your early 20s signals that you will have severe thinning for the rest of your life. It is great that you are on finasteride and minoxidil. These will go far for helping to prevent more loss. Even if you decided that you still wanted transplants in the vertex, I don't believe it would make a tremendous difference for you. It is a strange reality, but placing some grafts in an area with only a little thinning doesn't make as much as a difference as placing grafts in a very bald area. I believe you would be disappointed. Also, placing grafts in an area with already a fair amount of existing native hair could injure the native hair there. The best bet would be to consider growing you hair slightly longer to better cover the crown. Also, you could use topical coverup such as Toppik or the more permanent SMP to create an illusion of more density.
  9. This can be answered in a number of ways. One can talk about how long it takes for the graft to be physically adhered to the scalp. Also, one can talk about how long it takes before the graft can no longer be damaged by normal routine activities even if it is not dislodged. The graft itself after 4-5 days is very secure. Typically only the first day or two do we see the graft actually getting bumped out. When this happens, there is also associated bleeding from the hole that remains. As an example of how quickly the graft takes, we had a patient from another clinic come in for a visit. The patient was not happy with how low the hair line was placed and asked us to remove a number of grafts at 5 days since his surgery. It was very difficult to remove the grafts and only with considerable force using forceps were we able to take them out. After the grafts are placed and are secure, they still can be injured. We have the patient avoid sun for many months, because the skin is more prone to burning. A burnt scalp can diminish good growth of the grafts. Dyes or harsh chemicals should also be avoided the first couple months as these also can injure the scalp and potentially underlying follicles. The way you washed your hair at that time should also not have affected the growth. If you are concerned about the outcome of the surgery and growth you should see you hair tranplant surgeon for a complete evaluation.
  10. Yes, we matched up the number of FUT and FUE so we could have an fair side to side comparison. We also recorded transection rate. We did 2000 graft total for each case. For our clinic, that is an average sized case. If we had dozens of patients we would have a better time with the results. Unfortunately it is tough to get patient enrolled in transplant studies. I think, although this study will not be authoritative, it will give a good idea if there are large differences between the outcomes in both techniques. If there is little difference between the donor and recipient in both FUE and FUT it will also be important for the hair community to know. Thanks for the interest!
  11. Rashid36, Taking finasteride is not a problem. The study is taking place at Shapiro Medical Group in Minneapolis, MN, USA. Although the surgery is greatly reduced in price, we will require patients to return for follow up in the clinic at least 2 additional times.
  12. 1978matt, I am glad you asked. Currently we have 4 patients enrolled in the study. We are ultimately looking to do 5 or 6 total. The patients are at various stages of their post operative period. The results are very interesting though with the 2 patients we have at or near the one year post op mark. As many of us expected, the FUE and FUT sides look very similar. This is according to the before and after photography. We have yet to fully study the magnified views and hair counts to really see if there is a difference between techniques. Still, no difference would be seen as a valid conculsion for this study. If after looking at all 5 or 6 patients we determine that both FUE and FUT are equally valid, that will be a very useful piece of info for physicians and patients considering using on techniques over the other. There are additional aspects of the study, that over time, may become even more interesting than just the results in the recipient area. We are also looking at the effect of the donor region from each technique. We are trying to see which technique allows the most number of total grafts and how the visibilty of the scar fairs over time. It appears the more we learn, the more questions we come up with. We will update you as we can. BTW. We still have 2 spots available for the study. If there are any interested candidates please contact our office at Shapiro Medical Group. The procedure is at a very reduced rate. Thanks.
  13. I think Beard FUE would be an excellent way to help cover the scar. Typically we can get anywhere from 300-500 beard FUE grafts in a session. Because you have scaring also in the underside of the beard where we typically take the hair from, we would probably only get 200 -300 grafts. We could also take scalp FUE to supplement that. It is most likely going to take more than one session to really blend in the area. After one session of FUE into the scar, oftentimes the skin become more normal and softer. May goal for you would be to evenly place graft on the side and underside of your chin. That way, after shaving you would have a more even shadow.
  14. Rashid36 The good news is that body hair is for the most part DHT resistant. Over time and as you age, the hair does thin somewhat and also loses its color. It does not fall out though, like the scalp hair does because of androgenetic alopecia. The results that you may have had initially with body hair can be slightly lessened over time because of this. The bad new for people with considerably thinner body hair is that they are not good candidates for this procedure. In order for body hair to be effective, the donor hair must be somewhat coarse in order to make a considerable difference. It would still be technically possible to tranplant body hairs in someone with finer body hair, it would just not be very helpful in the overall results.
  15. I am not sure we know if beard and chest hair lasts a lifetime or not. My suspician is that body hair acts alot like the "safe" donor area on the scalp. It may very well last a lifetime, but it does undergo natural aging. The hair may lose its color and it may also get thinner over time. These changes would follow the tranplanted hair wherever they were moved. We transplanted about 500 chest hairs in this patient. These hairs we intermixed with scalp hair. The majority were placed towards the posterior part of the scalp in the recipient.
  16. Yes. This is an interesting phenomenon. There has been some research in this area in the past. Clinically I have seen that the hair does seem to look and behave like the surrounding hairs. This works well for beard hair that is transplanted into the scalp. Beard hair is usually coarser and doesn't grow as long as native scalp hair. Over time, I have seen that the growth cycles of the transplanted beard hair may lengthen slightly, and that they may become less coarse over time. This is not perfect though. The beard hair and body hair for that matter, always remain different than scalp hair. It is just that over time, they are "less different." It would be an interesting study to determine why this happens exactly.
  17. This is an interesting topic. Yes, we too have seen a slight bump in the number of ingrown hairs in the beard area. FUE in general, can lead to occasional ingrown hairs followed by some inflammation on the scalp or beard. These are usually relieved with warm compresses and topical antibiotic ointment. Rarely, if it does not improve on its own, an oral antibiotic can be prescribed. This is not harmful on the overall results, it is just troublesome to the patient. It is theorized that patients that frequently get skin infections are more likely to get these infections. Also, if there are any partially transected hairs from the FUE procedure, there may be more or less ingrown. At Shapiro Medical Group, we have worked with many different types of FUE devices. We have used the robotic, dull, sharp, motorized, and manual systems. All the while, we are trying to minimize the transection rate and improve the overall quality of the harvested grafts. The most recent device we have been using is the WAW trumpet hybrid punch by DeVroye out of Belgium. It has given us the lowest transection rate to date and delivers a very high quality graft. Our transection rates are typically less than 5%. My thought as to why there are more ingrowns being seen epecially in the beard are is not that the transection rate is high, it is just that we, (and perhaps other clinics as well) are doing many more beard/ body FUE than we have been in the past. More patients are asking for it, and more repeat FUE patients are running out of scalp donor hair and looking to the beard and body for more. I think that although the transection rates are incredibly low, the beard may just have a higher chance of developing ingrown hairs. I appreciate the topic and look forward to hearing from others' experiences.
  18. FUE has come a long way over the years. It has enabled many patients who would otherwise not have had a hair transplant procedure the ability to get one. It allows patient who wish to shave their hair shorter the freedom to do that. FUE is not without limitations though. FUE in general may not yield as many total grafts in a patient’s lifetime. The average patient can yield somewhere between 4000 and 8000 usable grafts over a number of procedures. Beard and body hair FUE has been available for a number of years. There is much debate as to how effective and useful this type of hair is. At Shapiro Medical Group, we have been doing FUE for a number of years and getting great success with our patients. Over the years, some have asked to try beard and body hair to add extra grafts. There is currently much debate amongst surgeons as to the usefulness of beard and body hair. Unfortunately, there are not any good studies comparing scalp and body hair FUE.We have been doing beard FUE on a regular basis for over a year with good results. We typically add beard for patients with a limited donor supply that still need to add extra density. Beard has been commonly accepted as a useful addition to the scalp hair with FUE. The yield is relatively good. Chest and back hair are other area of body hair that have been tried in the past. These areas of donor are less useful for a couple of reasons. First of all, most people don’t usually have a strong, robust amount of this type of hair. Also, because of the fine nature of the hair, the yield (how much hair actually survives) is usually very low. Some physicians think chest and back hair has a yield of less than 50%.Arm and leg hair is also used, but is usually finer still and also has a poor yield in general. With beard and body hair the area that the grafts are placed is also important. Because the characteristics of body hair is typically different than scalp hair, the body hair grafts have to be in less obvious area of the recipient scalp. We typically mix the body hair with the scalp hair so that the hair is helpful with density, but not very noticeable. The patient presented here was limited on scalp donor hair and desired for us to use chest hair. Thankfully, he had excellent, coarse chest hair.Also, the chest hair also contained a number of 2-haired grafts which is unusual in body hair. A close up of the area show a number of 2 –haired grafts. Also from the picture of the individual grafts you can see the grafts are coarse and strong. Because of the fine and fragile nature of the chest hair grafts we used implanters to place the grafts. This way, we could minimize the handling of the grafts. As I mentioned before, it is important to put the body hair in a useful but inconspicuous area of the scalp. The chest hairs were mixed with scalp and placed in the posterior of the recipient area. Just like in the scalp, the tiny incisions of FUE heal very rapidly. Here is a photo of 3 days post op. As we did with this patient, with extra care in handling of the fragile body hair in FUE, there may be extra donor reserve for other patients. We will update you on this patient.
  19. Mick50, Your current results look very good. Many patients have more than one procedure in their lifetime, and often wonder about how many grafts are left to work with. That is always a good question! Typically the standard answer is that most men have an average of 4000 - 8000 grafts available. Now that is average and some will be on the high end and others on the lower end. Alot of the variability comes from how your starting density is and also how quickly you lose your hair as you age. (i.e. someone with a large head, high density, and stays on hair loss prevention meds may have 8000+ donor in their reserve) Looking at your photos without measuring your donor density, it looks like you probably have donor on the higher end. I think you shouldn't have any problem doing another session with grafts to spare for any future need. If you are just talking about doing the midscalp and into the crown, another session may require anywhere from 2000-2500 grafts. Finally, after all the majority of you scalp donor is used, there is also the possiblilty of body/ beard hair for additional density if needed.
  20. The first World FUE Institute Workshop put on by the World FUE Institute (WFI) took place in the Canary Islands, Spain on Nov. 11-13, 2016.This newly formed society consists of hair transplant physicians from across the globe that place special emphasis on the advancement of FUE.The Institute exists to further the study of FUE and to form an educational space for physicians to further the field.Dr. Jose Lorenzo of Spain and Dr. Koray Erdogan of Turkey are the current president and vice president of the organization.They worked tirelessly to put together an excellent educational offering.Drs. Alejandro Chueco, Antonio Ruston, Alex Ginzburg, Bijan Feriduni, Hussain Rahal, Emorane Lupanzula, and Ron Shapiro were the other members of the faculty who each delivered countless lectures and performed surgeries in the afternoons. The location was ideal for the meeting and took place on the Spanish island of Tenerife off the coast of Africa. The weather was comfortable and the beaches along the coast were beautiful.There was a good turnout for a first meeting with around 50 physicians in attendance.I was honored to have attended and to have been asked to perform one of the live surgeries during the workshop. Day 1 started with an incredible amount of activity.In the morning there were a tremendous amount of educational lectures aimed at not only the beginning FUE surgeon but also those more advanced.There were lectures about the various types of FUE devices currently available as well as those being developed.Dr. Chueco discussed the different types of individual punches and how one can differentiate one size and type from another.Those in attendance were introduced to a new and exciting FUE device from Dr. Trivillini called the Mamba.It uses suction to stabilize the graft and also vibration to free it from the underlying tissues.Dr. Shapiro discussed the new motorized flat device from Dr. Jean DeVroye called the WAW.This device marries the ease and precision of a sharp punch with the transection-limiting nature of a blunt punch, giving a large percentage of high quality grafts. Drs. Erdogan and Lorenzo discussed a new topic in FUE planning called “Coverage Value.” This topic is sure to become very common for all FUE physicians in their surgical planning for the patient in the near future.The idea here is that the patient prior to surgery will be assigned a number based on their hair caliber, density and area of donor.Using this number (coverage value), the physician can determine how many procedures need to be done in a certain area to give a desired effect.Also, and just as importantly, the patient can find out how many grafts can safely be transplanted in their lifetime. There were talks given later that morning concerning the best way to place FUE grafts. Some physicians use forceps while an ever growing number of others are using implanters.The pros and cons of each were discussed.Finally, a description of the various types of FUE devices (manual, motorized, flat) was given prior to the actual live surgical observation. The first afternoon consisted of one case performed by Dr. Lorenzo. The interesting aspect of this case was that he used 4 different types of FUE devices on the same patient.He used the manual, Mamba, blunt, and WAW (DeVroye) systems. Day 2 again started very early with lectures.The first lectures from Dr. Ruston discussed ways of increasing the speed and efficiency of FUE extractions.Later some lectures went over potential complications of doing very large sessions (gigasessions of 4000+). Some of the talks dealt with the rising wave of poor quality work that is being done by inexperienced clinics throughout the world. There were a few lectures on how to tackle these cases and how to go about correcting poor work that was done.FUE into scars was a topic covered as well as using SMP (scalp micropigmentation) into areas. The afternoon consisted of 4 different patients performed by 4 different surgeons. The attendees were able to move about from room to room asking the various surgeons specific questions along the way.Dr. Ginzburg used his cordless motorized sharp device and placed those grafts with implanters.A manual technique with the patient in the upright seated position was demonstrated by Dr. Erdogan.He followed this by showing his new device called the “Keep” to assist in placing the grafts with forceps.Dr. Ruston used a motorized sharp system to extract while showing how he does the stick-and-place for placing the grafts.Finally, Dr. Feriduni also used a manual device with both an oscillation and non-oscillation technique to remove the grafts. Day 3 started with a discussion of the ethical way of performing hair transplantation on patients.Physicians also heard a lecture by Dr. Ruston about the “Red Flags,” or things that all surgeons need to be on the lookout for to avoid performing surgery on a poor candidate.There were also a few interesting lectures about body hair transplantation.Beard and body hair were discussed as alternate sources of donor in addition to the scalp.A specialized technique for eyelash transplantation was demonstrated by Dr. Feriduni. Poor growth and the depletion of the donor area was a topic of discussion as well. There was talk about ways to improve growth and to diminish poor yield in all FUE patients.Dr. Shapiro delivered his popular hairline talk showing the proper planning and placement of a natural-appearing hairline.Other physician speakers discussed their different techniques in designing an age-appropriate hairline. The final day of the workshop ended with another 4 surgeries performed by 4 surgeons. Dr. Lorenzo demonstrated the manual sharp technique on his patient.These grafts were placed with implanters which is common in his clinic.Dr. David Josephitis demonstrated the new WAW flat motorized device in another patient.This new device contains a foot pedal with adjustable speed and oscillation which allows the physician to tailor the speed and movement of the punch to minimize the transection rate and maximize the number of quality grafts.Drs. Lupanzula and Cueco demonstrated their techniques followed by the use of implanters for their cases. Overall, the first workshop of the WFI was a success.Ideas were openly shared in a friendly and collegial atmosphere.Many physicians walked away with new ideas and techniques to try out in their own clinics.
  21. andy, The WAW FUE is the device that we are currently using for over 90% of the FUE cases at Shapiro Medical Group. We have been using it now for almost a year and have been very happy with the quality of the grafts and the patient results. When it comes to FUE devices, they can basically be broken down into manual and motorized systems. Within those types they are also broken down into sharp or blunt - tipped punches. If you are familiar with the devices, a common sharp punch is made by Cole and a common blunt is made by HARRIS SAFE. I have tried all of these devices and they all have different pros and cons. The WAW is somewhat of a combination of the blunt and sharp. The punch is actually a flat surface so that it actually cuts through the surface as a sharp punch does, but also glides easily past the follicles like the blunt punch does. The punch also uses oscillation and not rotation, so it is much gentler during the deeper dissection. Currently we feel comfortable using the WAW with all different patients with many different hair types. We are finding the grafts are easier to extract and the grafts have more tissue around them too. There is also a lower transection rate with its use. We are excited to have this device and know that with time it will become more common with other FUE surgeons in the field.
  22. kalab23, I can understand your concern for future loss. It is good to think about the future and what type of pattern you might end up with. I think conservatively it would be appropriate to use FUT or FUE on the one. If you are very concerned about the scar and want FUE, that should be just fine. Because of your young age, I would recommend only filling in the area of loss and not extending much the temporal points. This will help to give you more security that if you lose more hair the pattern you create will not eventually look unnatural. I think if you create a vertical line connecting the top hairs to the bottom hairs and fill in behind, you will have a big change. Eventhough the other side extends farther out, there will still be an improvement. Remember also, that over time, there is a good possibility that the existing temporal point may also recede a bit. There is really no need to have to extend the point out much further on the thin side. In the future, if you see that your hair loss pattern has slowed down or you feel more comfortable, you may at that time of course move the point out farther. In the worst case scenario with FUE and future hair loss, you may laser or extract any unusual hair in this area.
  23. Justhadtransplant, Typically if a graft is pulled out or broken off at this point, the follicle has not been injured. These grafts should regrow like normal. We always advise not to pick the grafts or pull on them even up to two weeks just to lower the risk of permanently damaging hairs. In your case, I would suspect that either the follicle had just broken off and you were looking at a bit of dried blood or skin that looked like a bulb of the follicle. Otherwise, occasionally a graft during placement may be lying on top of the scalp and not in the incision. This graft may just be trapped under a scab until it is removed by water or the hand. This graft is of course not going to grow. Usually, if there is no fresh blood seen with a graft during the first week, then the graft was not pulled out. Actually is is quite difficult to pull out a graft after 6 days. In the clinic here at Shapiro Medical, we removed a few grafts from a patient who had been at another clinic. The patient just wanted a few grafts removed to help make the hairline more natural. The grafts after this time did come out, but were very tightly adhered already. Also, the resulting hole did bleed for a few minutes.
  24. TheGman, You will want to be careful when using chemical or physical straighteners or dyes for that matter soon after a hair transplant. The concern of course, is that you will damage the skin and / or hair and ultimately get a poor result. It is perfectly safe though to treat transplanted hair once it is fully mature. The hair should be just as strong and durable as native hair. Some people's hair grows faster than others, so it is really a matter of how quickly your transplant has grown out. At 6 months the transplant may be ready to straighten, or it may still be to early. Early and young transplanted hair appears finer and thinner than fully grown mature hair. If you are unsure if the hair is mature, it might be a good idea to check with your surgeon.
  25. After 3 weeks the grafts are safely secured and there is very little risk to losing any. There is really no concern to getting a haircut at this point. I would advise not to shave the hair very close to the scalp as there may be a possibity that you could cut or injure the newly healed scalp. This could lead to infections. Also too closely cropped hair might predispose someone to getting ingrown hairs which could be tender and also might become inflamed. The best bet would be too use some sort of guard on your trimmer and make everything even. This would not harm the grafts and give a nice and even look.
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