Ali Emre Karadeniz

41 year old patient had a previous 3000 grafts FUE procedure at another clinic that did not give the expected yield. The donor density was significantly reduced due to the previous procedure. A 4604 grafts FUT+FUE combined procedure was performed. A 25x2 cm strip was excised and the wound closed with single layer staples using trichophytic. A 0.8 mm motorised sharp punch was used for FUE. Graft distribution: FUT 1:210 2:1457 3:1135 Total:2852 FUE 1:492 2:820 3:440 Total:1752 Total 1:702 2:2277 3:1575 Total:4604 Photos were taken before, immediately after and 6 months after surgery. BEFORE IMMEDIATELY AFTER 6 MONTHS POSTOP

I recommend that you have another FUT. You can improve your scar while getting the extra grafts needed (if the skin is not too tight). IMO, it is a myth that a manual punch can help extracting curly hair. Lets imagine: Is the surgeon with the manual punch going to penetrate the skin, hit the hair shaft, feel it and change direction without transecting it? I don't see this happening. As soon as the sharp edge of the punch touches the hair shaft it is going to cut through it instantly. If a surgeon claims that he can swerve with the manual punch without feeling the follicle, then a sharp punch user can also claim the same. I would not be able to do this. If the follicle is curly under the skin, which is not necessary in every curly haired patient, then I don't see how a transection can be avoided in FUE. The fate of a totally transacted graft is not clear, however I don't think we should be very optimistic about it. A partially transected graft, that is a graft with an intact follicle and transected follicle(s) beside it however is different. I am currently on a scientific study that has currently shown me that at least half of these transected follicles beside an intact follicle can yield a fully grown hair (at the recipient area). I don't know what happens at the donor area. Further studies are of course necessary.

Dear Bill and all members of the forum, I admit that I did a very risky thing by putting clinics using technicians for FUE in Turkey on the operating table. I probably annoyed not only technician clinics, but clinics that have a reputable surgeon using technicians for graft extractions. It is not surprising that million dollar companies have representatives that even moderate their own forums to improve business and will accept no limits in promoting the clinics they represent. I would like to make it clear at this point that my motivations were not derived by a marketing strategy to downgrade these clinics as a matter of competition; it is all about patient benefits. Patients should be allowed to know what they are offered. IMO it is okay for a patient to go to a technicians clinic as long as he knows who is going to do the treatment and what he should expect from it. It is okay for a patient to choose a reputable surgeon using a technician for graft extractions as long as he thinks that a hairline design by this reputable surgeon is worth the investment. It is also okay to choose a doctors only clinic where all graft extractions and recipient site incisions are done by the doctor himself. This is not the thread to discuss this, but at this moment when an avalanche of trolls are attacking me for sharing my philosophy, which may have put other philosophies at question, I would like to clarify; Once a doctors reputation goes very high up in the rankings, it may not be possible to have this doctor do the whole procedure, from a business standpoint. After the price of a surgeon goes beyond 10.000-20.000 Euros per procedure, it is not possible to increase the price much. What can a surgeon do if he has a waiting list of 6 months and his price is close to the maximum? Can he start charging 50.000? I don't think so. Again from a business standpoint, there may be no option but to use technicians to be able to do multiple procedures a day. I am aware of this fact and have no intentions to criticise these institutions. However, I still think that the patients have a right to know that, the use of technicians in this case, is not due to the fact that technicians can do extractions equally well compared to this surgeon, or technicians can be used because hairline design is the only critical part of the procedure; it is a necessity dictated by business. I believe I have said enough on this topic; therefore I will stop posting my opinions that seems to encourage fierce arguments, as I am now spending all my time on the forum answering shills, instead of posting on scientific discussions and patient results. Dear Rossco123, I have sent you a couple of emails trying to answer your questions in detail, however I have not received a reply. I also offered to talk to you on the phone, as I believe talking live will be much more fruitful than posting on the forum under the shade of trolls, who love this opportunity to insult me. I will wait for a while to see if you would like to communicate with me. If not, I will answer your questions openly on the forum.

Swooping, you need to watch your language here. Who are you to call me a kid? You being a the representative of another clinic and a troll doesn't give you the right to insult a doctor. Moderators please... Swooping, it is not your business to determine the pricing structure of a surgeon. Charging by graft intervals is actually in the patients favour as it makes sure that the surgeon is not extracting grafts to make money, but is doing the best for the patient after the price is fixed. This is a topic that may be discussed separately, however your intentions of promoting another clinic while trying to insult me are unacceptable.

These are clever words, but add nothing to the topic. However I have noticed that you are able to type Erdoğan correctly with a 'ğ'. It is surprising that you are using a Turkish keyboard!! Have a good day!

This is a very complicated topic and deserves to be discussed in a separate thread. However I can say that it is a combination of multiple subtle factors regarding tissue characteristics. As I mentioned, there are a group of patients which the donor area looks perfectly good before surgery, but the FUE test shows a very high transection rate. Let me list the factors that comes to my mind now: 1. Unfavourable tissue resistance to the rotation of the punch 2. Splayed follicles beneath the skin 3. Bulbs that are too deep 4. Bulbs that are too shallow 5. For unknown reasons: topping if the punch depth is shallow and total transection when the punch is inserted slightly deeper. 6. Diffuse idiopatic fibrosis 7. Diffuse fibrosis due to previous surgery (may be suspected before) 8. Diversity of directions (may be suspected before) 9. FU's with a very acute angle on the skin (may be suspected before) 10. Splayed follicles above the skin (may be suspected before) And maybe more... Lets not forget that god didn't create our scalp considering that we would try to do a very sophisticated procedure as FUE! He didn't create us to have FUT, but strip removal is such an elementary surgical procedure that it can almost always be done despite various skin characteristics.

Another fact: FUE does not work on everybody. In some patients we can tell that it is unlikely to work, however in some patients we only find out after we do an FUE test. What I mean by FUE test is actually starting the operation and doing 100-200 grafts to find out about the transection rate and the quality of grafts. If I find out that the results of the test are unfavourable, I stop the procedure. I recommend doing FUT or totally cancel the procedure. Now, I think this should be a standard approach. How do we fit this in with technicians FUE? More importantly, how do we fit this in with FUE-only clinics. Without the chance of a doctor doing these evaluations and/or doing FUT, how do we think these clinics actually deal with these unlucky patients? Technician clinics will surely butcher these patients. I am not sure if FUE-only clinics , even if the doctor does the extractions, will stop these operations, give the patient his money back and recommend them to go to a FUT surgeon.

Just when I start loosing my faith in the forum a couple of wise members enter the thread making me feel that I am understood by some. But, could someone explain to me why the 'technicians lobby' is so strong and aggressive at this forum? It is tragicomic that I am put into a position as if I am trying to protect myself. Why is a doctor working on a single patient a day for at least 6 hours of hard work alone, has to defend his philosophy and representatives of technician clinics, stand up proudly and behave as if they are the kings of this field?

I agree and would like to add; Once I was asked to train a tech to do FUE extraction where I worked for previously and I did so. He was extremely talented and soon started getting excellent grafts with a low transection rate. He would run to me showing his excellent rates and we would celebrate. However, occasionally we would run into some problems. Sometimes he would over harvest from close to the neck region causing visible moth-eaten appearances. Sometimes he would make a slight mistake in angles. These were rare and the company was very happy with having this tech. What I am trying to say is that even if a tech is talented and trained well, he doesn't get the eye of a medical doctor. He doesn't have the responsibility and concerns that a doctor has, that enables the doctor to spot every danger in time and make the necessary adjustment. There are some rare parameters that you just can not remind the tech of for every patient. When that situation comes, he might be carried away with the standard thing he is used to do and make a mistake. Patients being operated by a tech actually pay a price even if the tech is very good. That is they miss the chance to have the doctors eye on them, constantly trying to keep them out of trouble. It is like Russian roulette when mostly nothing happens, but rarely it is a disaster. Clinics may afford the risk, but do patients?

I am prepared for representatives and trolls attacking me here, so it is no surprise. I will not go into discussion with such people who are usually at a lower intellectual level and more importantly are vulgar. The fact that I am making a comment here doesn't mean that I am answering you personally as your motivations to promote a technicians clinic has no intellectual value. I have explained this issue previously, so it needs no further comment. None of my postings are personal, but are intended to share my knowledge and opinions with a large community. Everyone can draw their own conclusions.

It is my patients who is going to tell if I have a golden hand or not. There is nothing to be gained from such unfruitful comments. It is neither going to put me off in trying to support the truth, nor going to change the reality that supporting technicians has marketing purposes rather than quality and patient benefit.

It is very simple; ISHRS either has to remove the consumer alert or members who don't comply with their principles. If I am not mistaken, it is now obligatory for members to sign a consent that they will not use technicians for graft extractions. I may not reverse the blowing wind, but I certainly can share my opinion. The reason why 'top doctors' use technicians is very simple: their growing business dictates that they must do multiple procedures a day. It is not possible to increase the price per patient more after a certain limit, however it is easy to increase the number of patients when using technicians. It is much more profitable to do multiple procedures a day even if the price is reduced. You are right. The blowing wind may end up all 'top doctors' using technicians one day. If this is what the market dictates then I may end up in the same way. However I will never claim that this is for quality; it will be the results of my growing business and the blowing wind that I were unable to withstand. I will do my best to keep the quality high, but I will know that it is impossible to clone my abilities by training a technician; just as it is impossible to clone the abilities of the other doctors you mentioned. It is an illusion that trained technicians can do the job with the same excellence as an expert surgeon and the only thing that matters is doing the incisions. This claim is the fruits of a doctor being able to cope with 3-4 patient incisions a day. When that clinic has 8-10 patients a day then they will claim just doing the markings is enough and the incisions can also be taught to technicians. Who can claim that a talented technician can't learn how to do good incisions? There is no end to this.

Seeking Hair Restoration Surgery? Be sure that a properly trained licensed physician* is responsible for your treatment. The International Society of Hair Restoration Surgery (ISHRS) is concerned about the growing risk to patients of unlicensed technicians performing substantial aspects of hair restoration surgery. The use of unlicensed technicians to perform aspects of hair restoration surgery, which should only be performed by a properly trained and licensed physician*, places patients at risk of: (i) misdiagnosis; (ii) failure to diagnose hair disorders and related systemic diseases; and (iii) performance of unnecessary or ill advised surgery all of which jeopardizes patient safety and outcomes. There may also be a risk that unlicensed technicians may not be covered by malpractice insurance. The ISHRS believes the following aspects of hair restoration surgery should only be performed by a licensed physician*: Preoperative diagnostic evaluation and consultation Surgery planning Surgery execution including: Donor hair harvesting Hairline design Recipient site creation Management of other patient medical issues and possible adverse reactions Post-operative care To help insure patients have information needed to make informed decisions about who performs their hair restoration surgery, the ISHRS urges potential patients to ask the following questions as well as questions regarding costs, risks, and short and long-term benefits and planning: Patients Should Ask These Questions: Who will evaluate my hair loss and recommend a course of treatment? What is their education, training, licensure, and experience in treating hair loss? Who will be involved in performing my surgery, what role will they play, and what is their education, training, licensure, and experience performing hair restoration surgery? Will anyone not licensed by the state be making incisions or harvesting grafts during my surgery? If so, please identify this person, explain their specific role and why they are legally permitted to perform it. Is everyone involved in my surgery covered by malpractice insurance? Consumer Alert | International Society of Hair Restoration Surgery

Are we talking about a specific technician here? If we were, then anyone who had an experience, together with the results could contribute into a discussion about this person. In light of such testimonials and evidence I would be ready to admire a genius. However in the absence of a specific person we have to stick with our generalisations. A question also arises: Why would someone posting his opinions here try to squeeze in a rare exception of a technician being much better at doing hair surgery than a properly trained surgeon? And why do I see this happening so frequently?

The principle you are basing your opinion totally defeats the principle of 'Licensing in Medicine'. If we accept what you are saying, then we could train a car mechanist to do heart surgery better than some heart surgeons, we could train a policeman to do better gastrointestinal surgery than some general surgeons and we could train a housewife to do a rhinoplasty better than some plastic surgeons and so on. There is no end to this. If we are talking about public health and safety, of course we have to generalise. We have to assume that in order to get the best average quality of hair transplants, with regards to safety, naturalness, donor and recipient area aesthetics, we should give a licence to physicians not technicians. I have to add that the term 'technicians' does not refer to a specific specialty with training in hair procedures, but is a mixture of people from various fields, including nurses, ambulance technicians, paramedics, laboratory technicians, biologists. I have even heard car mechanists, secretaries and housewives doing this. So you can imagine how much we actually need to standardise this in Turkey.

I don't think I need to say anything more about technician clinics as I have posted a lot about this. Me and my patients on this forum have been subjected to personal insults by them and their representatives lately. Meanwhile, I would like to add here that I am not against these clinics as long as they are transparent in what they do and the patients accept this. Anybody who feels they will never have a chance to have a proper hair transplant by one of the leading surgeons and are willing to risk their natural appearance to get some hair on top of their heads can and will continue to go to these clinics.

I think this is an excellent question. I believe time and graft number are both important. 5000 grafts offered in a single day is not to the patients benefit, however the surgeon can not charge 5 days if this is how long it takes him to do 5000 grafts. The per graft pricing is the most modern however it does not solve all the problems. Is doing a rushed 4000 grafts in one day more valuable done a carefully done 2500 grafts? I don't think so. Do all 2500 graft procedures require the same effort by the surgeon?. No, sometimes a 2000 graft procedure takes more working hours and effort than a 2500. Is it always to the patients benefit to have more grafts done? No. Patients usually think that paying per graft guarantees that they get the value for money, however it may not wok that way. This method of pricing may increase the motivation of the surgeon to do a higher number of grafts, regardless of the patients need. Or sometimes, when the case is difficult, it may be to the patients benefit that the surgeon slows down and does less grafts. Should he be under pressure to reach the number of grafts so that he doesn't lose money? My solution is to charge per graft intervals, taking into consideration if it takes half day, full day or two days to finish it. Once the price is decided and agreement made, I prefer forgetting about numbers for grafts and price. I like to concentrate only on the best possible surgical performance for the patients long term benefits.

Dear Seeker323, Having been operated by technicians has probably caused the following problems: 1. You probably weren't a good candidate for having a hair transplant, however technicians are not trained to behave according to medical ethics and always give priority to patient benefits that physicians do. 2. The donor area was over harvested with clusters of defects causing a moth eaten appearance. 3. The transection rate could be up to 70-80%. This means that the deficiency at the donor area can be much higher than the hair used for coverage and coverage at the recipient area may be much less than expected from the graft number. You need to wait and see about this. 4. The hairline is designed too optimistic compared to the modest graft number achieved. The transplanted area is much wider than the graft number normally deserves. Therefore, the expected density at the recipient area is low. I am sorry for the pessimistic evaluation of your situation, but we have a lot of experience in seeing situations like this, as Turkey is the world of technicians hair transplants. I wish you good luck.

Here is the other troll in action! The picture is as exactly as PupDaddy is explaining. Thank god some members are aware of what is going on or else patients and doctors without trolls behind them are going to be crucified here.

GraveD11gger, I think you have to watch your words here. Whether the previous clinic Pianist went was famous or not is not relevant to the patients desire and right to share his experience here. The fact that you want to represent Dr. M here is no reason to insult my patients or ask me questions that are designed to cause destruction. Everyone knows that I try to answer any question on this forum, but this troll-like behaviour is unacceptable. In my first days of my membership, Dr. M called me and asked me not to post my opinions on threads related with him. Although my posts are purely medical or informational, but never personal, I promised him that I wouldn't post on his threads and have kept my promise so far. After your post, I had to call him and ask him and his representatives to be civil and not post destructive messages on threads related with me. I am sure he understood. Anyone can ask me questions, even his representatives, but the language has to be civil. This forum can not be an environment where competitors try to bash each other through hidden representatives. I would like moderators to share their opinions on this aspect.

Dear KO, Both of those clinics he is mentioning are technicians clinics. When you have a look at their websites (I just did that) you will not see any doctors name assigned to hair surgeries. So, there is no chance that there are doctors there who can develop a good reputation and branch off later. The only clinic that had doctors to do hair operations was the one I used to work, where the scenario you mentioned happened and the clinic was left with a single surgeon. This clinic can no longer train new surgeons as all the senior ones have left. There is no hair clinic in Turkey where new hair surgeons can be trained.

Dr. Haber mentioned in his post that the patient had limited finances, so that means he would have offered a higher number of grafts if the patient was prepared to pay for it. There is no doubt that Dr. Haber must have explained in detail the patient what he should expect, as he is a very senior and respected hair surgeon and a member of ISHRS, that I adore. What I am trying to say is that it may not be sufficient to lets say build a safe relationship between the patient and the doctor by just explaining what to expect, as the patient will always have in his mind that the doctor didn't do the ideal treatment he had in mind, but tailored it to the patients budget. I would like to add that there may be some cultural differences between countries. A patient in the USA may tolerate better and/or may be expected to tolerate a treatment plan designed according to his budget, however a patient in Turkey would never accept this. He would feel insulted and not only that he would refuse the treatment, but he would also speak against the doctor when talking to other people. He would not see it as a natural result of his limited budget. I wish it were the other way round

The decision on where to go in Istanbul for a hair transplant could be determined by considering 2 factors: 1. Type of hair clinic: A. Technician clinics where the whole procedure is done by technicians. B. Clinics where technicians do graft extractions and the doctor does recipient site incisions. C. Doctors clinics where doctors do all graft extractions and recipient site incisions. 2. Price A. 1000-2000 Euro price range B. 2000-5000 Euro price range C. 5000-10000 Euro price range Interestingly, when you analyse clinics for these 2 criteria, A in 1 doesn't always match A in 2, B in 1 doesn't always match B in 2 and C in 1 doesn't always match C in 2. You will see some alterations depending on brand name.

There is no doubt about Dr. Haber's experience and skill in hair surgery. This is obviously a very natural result and I congratulate him for it. The problem encountered is a typical situation where a treatment plan is formulated according to the patients budget. Even if a patient initially accepts a modest result with a modest graft number such as 1200 grafts, he is always going to feel frustrated and even angry that the doctor offered him a suboptimal plan that was designed to the patients budget; put it the other way, designed to take an amount of money that the patient is prepared to pay. I refrain from this approach, as the danger of the patient feeling robbed, instead of being treated is too great, even if the result is the best that could have been achieved. On the other hand, the patient made a mistake of deciding on a treatment that is tailored to his budget; he should have looked for a clinic that is prepared to do the optimal treatment for the budget he has, or else he should wait until he has the necessary funds to have the best treatment offered by his doctor.

It was a male patient! Doing FUE first is an interesting idea and it turned out that the patient was hoping exactly for this. However, if I did it during the same procedure, it would prolong the anaesthesia time enormously. If I did it a while before surgery then I would have to do extensive local anaesthesia, as the donor skin would be very wide, considering the few grafts it is going to provide. I would have to do tumescence just like doing liposuction. Beside all these, I would have to charge the patient too much in return for what he is going to achieve. One funny thing is that I don't actually need the skin to be on the patient. I could do FUT or FUE while the piece of skin is on the table! Think it this way or that, it just doesn't sound right