Ali Emre Karadeniz

Mickey85 is correct. I am no longer a recommended doctor on this forum because I decided to cancel my sponsorship in August. I was not happy with the way this forum operates and how I and my friend and business associate Joe was treated. When I made the announcement of my departure with detailed explanation of the reasons it was deleted within ten minutes, which is why none of you were aware of my exit. I replied to a recent question on this thread that came to my email account, but this does not mean that I will be back as a recommended doctor. I frequently post on other forums however so I have not disappeared. In fact, I am quite active and quite busy as well. This is my final post on this. Thank you for your kind comments. I wish you all the best.

Density is defined simply by the coverage per area. This is the number of hairs (not grafts) multiplied by the diameter of the hair shaft. People tend to think of a graft number and the expected coverage from this number, but frequently forget considering the area to be transplanted. In small heads with a balding area that is narrow all across the head, 100cm2 may be 2/3 of the balding area, where as in wide foreheads, only the hairline and frontal forelock may be more than 100cm2; just like in this case. Besides, the hairline needs a much higher density for a satisfactory coverage than lets say the midscalp. So in wide foreheads we may end up using 3000-3500 grafts just at the front, in spite of designing a high hairline like in this case.

Thanks Stinger99, Ontop and Sean for your positive comments. Please note that from the 2502 grafts that were extracted, the total hair count was 7258, which means an average hair per graft rate of 2.9; that is an exceptionally high number. Such good quality grafts can be obtained only when there is a combination of a good donor area and a good surgical technique. People frequently talk about graft numbers and forget that it is the number of hairs that gives the coverage. The value of these grafts in my opinion are comparable to 4000 grafts with a hair per graft rate just below 2. This may open a new discussion that is perhaps too complicated to cover here; that is, 'if it is always to the patients benefit to try and get the highest number of grafts. This obviously leads to a lower hair per graft rate due to, 1. Using a smaller punch than needed to be able to make more punches per area. 2. Having to extract from areas that may contain too many nonpermanent hairs. 3. Having to extract from areas that contain follicular units with a lower hair number. 4. Increasing the speed of extraction while trying to finish the high graft number in that session. 5. Fatigue of the surgeon. It is possible to avoid the last two by dividing the session into two days, but the first three can not be avoided. We can add to all the above that the yield may also be better with these smaller number of healthier grafts that have a lower transection rate and thus a high hair per graft rate.

This 46 year-old patient with a Norwood 4A hair loss pattern with persistent frontal tuft, came in for FUE. 2502 grafts FUE was performed using a 0.8mm motorised sharp punch. The graft breakdown was as follows: Singles: 250 Doubles: 600 Triples: 800 Quadruples: 852 A conservative hairline was designed after discussing options with the patient, so that the upper part of the crown was also strengthened. Custom made pre-cut surgical blades were used to do sagittal (parallel) incisions. Photos were provided by the patient 12 months after surgery. BEFORE AND AFTER 12 MONTHS

Thank you, Wylie, for your contribution to this thread. I agree that the term "plug" may not be the exact term that describes what type of repair this is, as the donor scar itself dictates that this was a primitive version of FUSS. Perhaps the term "pluggy" and not "plug" could have been used to describe the previous work instead. There are a few points to consider about these "pluggy" mini-grafts that I removed compared to actual punch plugs. A case like this is much more difficult than traditional plugs, because at most one will have maybe 300 to 400 plugs spread thoughout the scalp. However, this patient required 2000 grafts removed very low on the forehead and more work is still needed. The spacing between grafts was much smaller than would be found in a traditional plug case so the extractions also had to be closer together. A much smaller punch had to be used to be able to make more extractions per area, while creating the smallest scar, but then it was more difficult to extract the whole graft. Beside the difficulties in managing the recipient area, the donor zone presented with a wide and low donor scar that needs to be removed carefully and in multiple procedures, which leaves no doubts that this is a complicated repair case. I appreciate your pointing out the reference and perhaps it was not the best descriptive I could have used but in reality the word used to desribe the problem is insufficient for the type and amount of work involved. The point of this presentation is to show how one case obviously in need of extensive repair can be addressed using multiple methods at the same time in a complementary fashion in order to get the best result possible for the patient.

Thank you, Sean. I try to discuss both options in every patient unless they clearly state that they are interested in only one of them. However, patients seeking a hair transplant in Turkey almost always want FUE. I did discuss both options with this patient and he decided to stick with FUE. His characteristics were favourable for a successful FUE procedure so we moved forward with it. With the results so far it seems to have been a great decision.

It is about 80% FUE and 20% FUSS. RecedingTide, irishsailor, stinger99, darlinglocks, thank you for your comments. Thank you Bill. You are right; patients who don't educate themselves by reading forums, don't know what to expect from a hair transplant which sometimes results in complaining in situations when most of us would be quite happy.

Thank you David, Sadbuttrue, Mick50, Johnboy71, Cant Decide for your input. I believe there are some situations when the Combo may be valuable. These may be; 1. When the donor capacity is reduced due to previous surgery. Due to pervious strip surgery, there may be little skin laxity to get a strip that is adequate and/or due to pervious FUE the donor density may be reduced. 2. Very high demand of grafts to achieve an acceptable coverage in high Norwoods. Although I now tend to prefer a large strip (4000-5000 grafts) to start with and leave FUE for later sessions. 3. When the patient comes in for FUE while asking for a scar repair. If a patient has a previous strip scar and comes in for a second procedure (usually FUE), I mention the possibility of a combo, which could improve the scar and give additional grafts at the same time; instead of doing only FUE and having to use some grafts on the scar.

Thanks all for your input. I was very surprised to receive these photos from the patient after hearing that he wasn't happy with the progress so far. I am hoping that he will improve more in the coming months.

I agree with Dr. Vories. I also would not want to be involved in a debate here, but I will share my experience, how I got to know Joe and what kind of relationship we have, so members can judge for their selves. It has been a little over 6 months that I became active on HRN. At first, I was kind of naive and got involved in a lot of discussions. I thought that discussions were all genuine and they were intended to share experiences and opinions. It quickly became evident to me that there were a lot of hidden reps/trolls that were acting according to an agenda. I was attacked and bashed by these members after sharing what I see and think about technician-only clinics in Turkey. I was even contacted directly and threatened by these clinics. To the credit of this forum, most of these trolls were banned later on. But I had learned my lesson and became a quite surgeon just like many others; just sharing patient examples. The simple fact that surgeons are on with their names and members being anonymous makes it impossible to be active without being hit by trolls. Shortly after, I saw Joe's announcement that he became independent. I did not know him up to that point. I called him, introduced myself and told him I would like to ask him some questions about how things work in the hair transplant industry. Our conversation quickly led to a friendship and then a partnership which we called 'online reputation management'. Now, this is a service offered by no one in the world that I know. I doubt if anybody could, because this is not a typical thing like having a representative or a marketing manager. It is a much broader term, which may include online image, medical ethics, patient service and care, relationships with other clinics, documentation of work and so on. Please keep in mind that most of these things are not even written in our agreement; these are services that Joe would provide voluntarily. On the other hand, the service does not include recruiting new patients or advising all patients to come to me. I have not had a single patient come to me this way and I don't expect Joe to find me patients. It is evident that the online environment today for hair transplant candidates and surgeons are forums. However, the way surgeons use forums need to managed professionally, or they may result in more damage than benefits. We do witness surgeons getting into trouble because of not managing their online reputation professionally. Forums make money by charging surgeons for listing. Good quality forums like HRN have a screening system, however even then there are too many surgeons listed that makes it impossible to give an advisory service for each clinic. Very close competitors of each clinic are listed, so we can't expect to get advice from a forum, the way Joe can give, who does not take on close competitors which would prevent him from being productive. As a surgeon, I appreciate the value of HTN, the screening process it uses for surgeons, the services it provides and its culture for free speech. However, it is clear to me that I benefit from Joe's advices too, which I see as a totally different service than I get from forums.

BEFORE AND 13 MONTHS AFTER

29 year old patient with a Norwood 5 / developing Norwood 6 hair loss pattern came in for FUE. 2770 grafts FUE was performed using a 0.7 mm motorised sharp punch at low RPM. The graft breakdown was as follows: Singles 700 Doubles 1370 Triples 700 I designed a conservative hairline without closing the temples to prevent the patient from running into trouble if hair loss progresses. Custom made pre-cut surgical blades of 0.5, 0.6 and 0.8 mm were used to perform sagittal incisions. About 2400 grafts were used at the front and the rest were placed lightly at the crown. The patient surprisingly contacted us at 5 months with the following after photos mentioning that he didn't think he saw any improvement! BEFORE AND 5 MONTHS AFTER

The scar repair and strip surgery was initially planned to be in a criss-cross fashion. In the first session the middle and right side of the scar was removed with a skin strip at the left higher temporal area taken for grafts. This time I will remove the left side of the scar, leave the middle portion untouched and take a strip from the right higher temporal area. I will probably remove more plugs as the directions are very wrong and hairs stick up in spite of being surrounded by new grafts. The transplant will be concentrated at the front two thirds. I will decide if I am going to do any FUE in this session or leave it to a third session. This will depend on how much I will work on taking out plugs and the duration of the procedure. I believe atleast three sessions are needed for a good restoration.

Thanks David, Busa and Motoro. The patient will be coming in this week for the planning of his second session. I will keep the forum updated.

PHOTO IMMEDIATELY AFTER PLUG REMOVAL PHOTOS IMMEDIATELY AFTER PLUG REMOVAL+GRAFT PLACEMENT

36 year-old patient who is a developing Norwood 6, had a FUSS procedure 8 years ago at a Turkish clinic. He does not remember the doctor, but he says this was a foreign doctor. The strip was removed by a doctor and then the rest of the procedure was performed by technicians. The patient is a pianist and told us that the unnatural look of his hair caused him significant problems in his social life. Close examination revealed the following problems: 1. There were about 2500 grafts placed very low at the hairline, with almost a right angle on the skin and sometimes even backward facing. These grafts were mostly 3 and more haired. 2. There was a scar approximately 1cm in thickness at his donor area. The incision was placed too low, almost touching the ears on the sides. 3. The fact that his previous surgery being FUSS was a blessing, due to the preservation of significant donor area, as opposed to many FUE patients that lose their donor through too many extractions. The donor outside of the FUSS scar was untouched so it was a virgin zone. The surgical plan consisted of combining these three goals in serial surgical sessions: 1. To remove close to all plugs with the smallest possible punch and redistribute them such that the hairline is pulled back about 1.5cm at the midline and 2.5 cm at the corners. 2. Repair the whole scar while utilising the skin laxity that is left for maximal graft harvest via FUSS. 3. Leaving FUE and BHT for future coverage. Since it would not be possible to repair the scar and at the same time maximise graft harvest with a single FUSS incision - due to the too low and straight incision - a criss-cross type of repair was mandatory. I decided to take out the middle and right side of the scar with a strip taken from the upper left side and do the opposite in a subsequent surgical session. SURGERY: 1500-2000 plugs were removed using a 0.6 mm motorised sharp punch at low rpm. FUSS was performed and the wound closed with double layer trichophytic closure. Graft distribution: Singles Doubles Triples Total FUE: 200 600 75 875 FUT: 257 1413 317 1987 TOTAL:457 2013 392 2862 Grafts were placed between removal sites using coronal incisions using custom-made pre-cut blades. The transplanted density was lower than usual as the plug removal sites had to be left empty. Please note that this is a repair procedure and photos at later stages including results of subsequent sessions will also be posted. BEFORE AND 6 MONTHS AFTER

An Fue Test or 'Fox Test' is a very important step before proceeding with a large FUE session. Unlike FUSS, FUE is a procedure that requires favourable tissue characteristics that allows for easy extraction of grafts without significant topping, shearing and transection of the grafts. Unfortunately, the public widely thinks that FUE is a straightforward procedure that can be used on every patient. However, some patients are not good candidates for FUE. The challenge is that, this can only be found out after doing an FUE Test, a test that has to be performed either at a separate visit or at the beginning of the procedure itself. Due to practical factors, we almost always get the chance to do the test at the beginning of the surgical procedure. The test actually is a subjective evaluation of how easy the graft extraction is for the surgeon. The ease of extraction is directly related to the yield of good quality grafts. If the FUE test is rated 'unfavourable' by the surgeon, he should sit down with the patient an reevaluate surgical options. If the extraction is very unfavourable then the options should be doing FUSS or cancelling the procedure. If it is unfavourable, but still possible, yielding a lower graft number, then the patient should decide between proceeding with FUE, doing FUSS or totally cancelling the procedure. In our case, the extraction was unfavourable but not impossible and the patient chose to proceed with FUE. It should be noted that, FUE-only clinics don't widely use the FUE test, as an unfavourable extraction would lead to being faced with cancelling the operation frequently. Not being able to offer FUSS decreases the motivations of a surgeon to find out if the extraction is going to be favourable or not. It is hard to imagine an FUE-only surgeon doing an FUE test, occasionally cancelling the procedure after rating the test unfavourable and advising the patient to go to another clinic. Some of the patients that we hear about getting poor yield after having an FUE procedure are probably related to this problem.

36 year-old patient presented with a Norwood 5-6 hair loss pattern. He had fine hair and requested an FUE hair transplant. The FUE test performed at the beginning of surgery showed an unfavourable result and patient was advised to have FUSS, however the patient refused this option. 1450 grafts were extracted via FUE and placed at the frontal area. The photos were taken at 10 months post-surgery. The patient used 5% minoxidil.

Now, what is this to do with the discussion above that you quoted? Nothing, of course! It is just a result of your motivations to promote another surgeon and bash me while doing so. How do you know what the real conversation was between me and that patient, were you there? I don't care about whether you would prefer me or not, but we have to be civil here in talking to each other or mentioning about each other openly on this forum. Just to let everyone know, what actually happened was, I mentioned along emails that we could get some grafts while doing the scar revision to add density to the hairline, as the patient told me he was planning a separate FUE session later for this purpose. The patient could have received additional density at the hairline without extra charge at the same session while getting his scar revision. Just a couple of minutes before the procedure I reminded him of this possibility, but he still didn't want it. It was at this point that I told him, 'if you say so'. That was intended as a polite way of letting him know that he is about to miss a favourable opportunity and I would have still preferred to put some grafts at the hairline.

Dear Busa, I see that you make negative comments about me from time to time. It is your right to prefer another doctor in Turkey and not see me as your first choice, but I would appreciate if you make statements about my practice if you really know about it. How do you know what my statistics are in doing FUT, FUE and FUT+FUE? In fact, FUT+FUE is about 5% of my practice. I also don't see the point in you saying that no other top FUE surgeons frequently use FUT+FUE, as by definition they are FUE-only surgeons; at least the ones in Turkey are. So we don't expect an FUE-only surgeon to use FUT at all, whether alone or in combination with FUE.

31 year old patient with a developing Norwood 4-5 hair loss pattern. 3000 grafts FUE procedure was performed. Graft distribution was 440 1's, 1060 2's and 1500 3's. 2300 grafts were placed at the frontal area and 700 grafts at the vertex. 0.8 mm motorised sharp punch was used for FUE. Custom made pre-cut blades of 0.6-0.9 mm were used for recipient site incisions. Coronal incisions were used at the frontal area and sagittal incisions were used at the vertex. Photographs were taken before and 9 months after the procedure. BEFORE 9 MONTHS AFTER

Rossco123, I would reply to your questions and comments forever, however in this previous statement you have carried it to a different level by saying 'we' and naming yourself together with representatives and promoters of other clinics, if not trolls. I never accused you of belonging to such a group of people, but you chose to name it that way. Therefore I will have to stop making comments here. I believe I have said the necessary things already. You can call me or email me any time if you have further questions and I can answer them privately. I wish you the best of luck with your future progress and hope that the result you get will make you happy.

Rossco123, I have tried to answer your questions many times and to find out where your dissatisfaction comes from, but it seems I have not succeeded. Looking at what youı have been saying I see that your complaints are concentrated mainly at two points; the graft number and the hotel. I would like to clarify these issues publicly here. 1. The pricing at that time was fixed for 2000-2999 grafts and the financial agreement made. We did exactly 2000 grafts, so the graft number was done according to the agreement and our company does not owe you anything for that. Whether some prefer the per graft pricing or the pricing for graft intervals is another discussion. I did mention to you in an email that you may need 2500 grafts, but this was nothing to overrule the financial agreement. It was an estimation of graft number that I decided to lower after examining you closely, as you did not need more than 2000. If I had decided that you needed 2999, I would have done it with no extra charge. Besides, you did not mention at the time of surgery that you wanted 2500 grafts or else you would complain. If you had mentioned me your concern, I would have easily extracted 500 more grafts, handed them to you and asked you what you intended to do with them. It would have taken me at most another hours work. So, I don't see why you suddenly appeared on the forum, complaining about the graft number when it was too late to do anything about this. 2. I had over 200 international patients staying at the hotel you stayed at without significant complaint. At least half of these patients were from the UK. I am aware that this is just a bed and breakfast hotel intended for an all-inclusive hair transplant package that kept extra costs at minimum. I did upgrade my patients to a 5-star hotel when patients asked for it and were prepared to pay the extra cost. In fact, after increasing our package price slightly it has been possible to include the 5-star hotel with no extra cost, but your package price was when it was cheaper. You mentioned to me the day of surgery that you had a problem with getting breakfast, so I told my nurses to serve breakfast at the clinic and they did so. If you had told me you encountered the same problem the day after surgery, I would have invited you to the clinic to serve breakfast once more, or told the nurse to serve you breakfast when you came for a wash. After you insisted that you did not get the breakfast you deserved and made a really big fuss about it, I had to ironically offer you a 10 Euro refund for the missing breakfast as this is the actual cost of the breakfast. The offer was not intended to be insulting, but was the only offer I could do after you complaining so much about it. When you sounded much more communicative on emails, I offered you a free night at the 5-star hotel for anytime you came to Turkey, as a gesture, but it seems my offer has worked the opposite way. Please note that this offer was given just out of good will, not because I thought we owed you anything. Finally, it has recently been obvious that the 'Turkish technician clinics trolls' are aggressively active on the forum in trying to devaluate recommended surgeons on the forum. Representatives of these clinics are using every chance to insult surgeons that do serious work. Complaining patients are an excellent opportunity for them to damage surgeons reputations by provoking destructive discussions. I have even been accused of using technicians for graft extractions while being the only recommended Turkish surgeon that does all graft extractions. Members should be aware on what is really going on.