Raphael84

The patient had previous surgery resulting in a sparse hairline with mis-angled grafts and an unnatural appearance. AGE: 31 MEDICATION: Finasteride HAIR CALIBRE: Medium fine OBJECTIVE: To remove the offending grafts and re-design and appropriately drop the hair line which was achieved with just over 2000 grafts. BREAKDOWN FU/HAIRS 1s - 421/421 2s - 1201/2402 3s - 371/1113 4s - 187/748 TOTAL: 2180 Grafts - 4684 Hairs AVERAGE HAIR PER FU - 2.14 VIDEO: PRIOR TO SURGERY POST SURGERY JUST OVER 4 MONTHS https://i.imgur.com/VCYnwKp.jpg 7 MONTHS 17 MONTHS

UPDATE! After such a satisfying result and a very positive experience, the patient desired to return to the clinic for a further session to increase density in his crown area and place grafts into his previous strip scar that was performed by another clinic. We will of course update regarding his most recent procedure and his journey in due course, but in the meantime we wanted to share the following video showing a comb through of his hairline from his previous session with BHR which you can see presents the most natural of results with impressive density, especially as a repair patient.

I post a response here as BHR Clinic and Dr. Bisanga are being discussed somewhat unfairly in terms of the requirement of consultation being "ridiculous". We will all have our own perspectives which is understandable, but if I was in a position to invite any individual to come and attend a full day of consultation where the doctor will meet numerous individuals throughout the day I would very much like to do so. Of course I cant with patient confidentiality, but you would be extremely surprised to find that several individuals with apparently good heads of hair presenting lesser Norwood patterns and what would appear to be solid donors, to actually present an unstable environment in terms of their donor when assessed under magnification and the risk of yield and growth would be high. I ask if you may have had the opportunity to assess donor areas under magnification and become intimately knowledgeable of them? I would suggest probably not, and there lies the lack of understanding. Just these last weeks at the clinic, two patients who did not appear to present any problems in terms of candidacy from photos, showed some suspicions within their scalp and potential inflammation that looked liked LPP (scarring alopecia). In both cases upon biopsy with their own sourced dermatologists, scarring alopecia was confirmed and a years treatment has now begun for both patients. LPP can not be cured and even with treatment if becomes inactive, surgery itself can trigger the condition and cause further and extensive loss. What would have been the case if both of these individuals had proceeded with surgery based on their photos and achieved little to no yield and actually lost more hair due to surgery being performed? That would have been terrible and a "ridiculous" and unethical decision. Consultations are not just about hair. They are about the integrity and the environment of the scalp, which in most cases, can not be seen to any degree in photos. These consultations can honestly bring you close to tears. Being a patient myself and knowing how hair loss impacted me as a young man and the extents I went in terms of holding down 3 jobs and saving every penny to be able to finance my first procedure, to see men attend consultation and the pain of loss is written all over their faces. They are overcome with emotion, especially those who have had previous surgery and may be unsatisfied. Many patients due to loss have struggled with anxiety and/or depression, this is common and so the idea of proposing surgery to patients without any empirical data to support the fact that they may or may not be a candidate, and to propose surgery and encourage that hope to then potentially find that they may not be candidates for surgery or may be borderline at best and the objectives that they discussed and desired may not be within reach, can be very negatively impactful to individuals. Having committed to surgery, invested both emotionally and financially to their perceived outcome and result, only to find that this is not the reality of their case and situation. We have never encouraged a patient from outside of Europe to travel to Brussels for consultation so to suggest the "private jet" and "demanding" theory is distasteful. I also understand the geography of the US and that Maryland consultations are not convenient or feasible for all, but obviously the doctor is not able to travel to each state and all locations. Again, we will all have our own perspectives and whilst other clinics will book purely on photos, I very much hope that come the time of surgery that those who have concerns with the requirement for in person consultation do not then find themselves in a position where candidacy is declined after such extensive travel and expense, or exponentially worse, the clinic proceed with surgery on a patient who really is not a viable candidate and therefore concerns will present themselves either in the short or long term. This forum presents many surgeons for your consideration. If you have concerns with one surgeons approach, then you can simply disregard him from your consideration. That is absolutely fine and actually encouraged. But to then publicly and on many occasions and threads, take issue with the fact that he is ethical is also "ridiculous". For those that may be new to the discussion, please find a previous post linked further explaining and discussing this very point. I genuinely wish that everybody was a great candidate for surgery but naivety and ignorance is not in anybodies best interests. I wish everybody the best in their onward paths.

The patient shared an update with me a few weeks back and he is progressing nicely and happy with his progress. I will ask him if he may be able to share an update when possible. Patient physiology will have an impact just as it will in regard to healing, redness, shedding as some patients may shed all and others are able to retain a percentage of grafts and also final result. In terms of early growth, 4 and 5 month growth now in general for our patients is really quite impressive and certain protocols have an impact on this. The way in which the grafts are extracted from the donor, handled, manipulated and then carefully placed presents less trauma to the follicle which is all conducive to early growth.

The patient reached out to the clinic and explained that he wanted to address his recession and thinning in his frontal third in this surgery. The patient presented fine hair and a lot of single and two haired grafts in his donor as is common for this hair type. The patient was not on medication but advised to begin post-surgery and has been on oral minoxidil since. The patient is very happy with the change this hair transplant has made and said it is beyond his expectations and thus happy to share it. A big thank you to him for documenting this from healing through to the 13 months. FU/HAIR BREAKDOWN 1s - 421/421 2s - 1295/2590 3s - 1025/3075 4s - 59/177 TOTAL 2800/Average 2.2 VIDEO:- PRE-SURGERY POST-SURGERY 10 DAYS 8 WEEKS 3 MONTHS 6 MONTHS 13 MONTHS

Congratulations for completing your surgery @Hah6788887 I know that any two days of surgery can be tiring and take a lot and I know that there was anxiety coming into the surgery which is common, especially with patients who present a repair status and have had negative experiences previously. We encourage all patients to share their cases and experience and this is the very value of the community and this presents a platform to then be able to discuss and allow users to educate and understand the challenges and realities that various case types may present. As has been requested throughout the thread, to present any real context to your case and some of your concerns, I feel that photos really would be a valuable addition whilst explaining some further background in terms of limitations and challenges that were in place as your surgery was not a typical or straightforward repair surgery as such based on specific objectives, donor limitations and donor sources. The great thing with the HTN community is that it is active and you will no doubt receive the support that was the motivation for your post, but to allow more specific and honest support, then I believe that your photos will answer many of the above questions and present some clarity and context. I will avoid sharing any specifics because naturally that is between yourself and the clinic, but would encourage you to share as much as possible and the clinic can then add comment that can help to potentially better understand some concerns or further detail. As detailed in my correspondence to you - As we have discussed, a surgery of such complexity isnt as straight forward as one may imagine, and as specific graft numbers were not known at the time of pre operative consultation as the doctor was not aware of the integrity or quality of grafts from other requested sources, then as there was a flexibility with graft numbers, that then extends into surgical approach as different options and understanding of graft and hair numbers become known as surgery proceeds. Day 2 presented a review and further discussion prior to surgery between yourself and the doctor as was requested to better understand the days approach. In terms of temple placing, I was personally hesitant regarding this as you will recall and explained that oftentimes it isnt as simple as stating that you would only like to place 50 grafts into the temple. Graft requirements are often higher and when miniaturisation is present, then to reinforce further behind is often necessary to avoid native hair becoming disconnected from transplanted hair with progressive loss, especially considering your pattern of loss and undoubted progressive loss. I recall our conversations explaining that I would not recommend touching your temples with the extent of your loss and graft demands throughout the scalp. One very significant point that I believe is being overlooked is that as was discussed and as you explained, your intentions in the future as loss evolved is to shave down and that one objective of many was that shaving down would present a natural head of hair, albeit with thinning. Considering this key element and the likelihood that it will at some point become reality, to not allow the doctor to restore into areas (such as deeper into the temple and some parts of the crown), that you do not consider priority at current, but would clearly become problematic in the future as loss progresses if these areas are not reinforced. This is a matter of ethics and can not be overlooked by preferred styling options today. As we discussed, if there are areas that become disconnected (the temple is a perfect example), this will not appear natural and so this must be taken into account and explains why the doctor felt the need to reinforce some areas more than you may have prioritised based on your current status and therefore why some flexibility once surgery began was needed and that trust in the doctor in utilising his experience to make such decisions based on the patients best interests is paramount in any surgery and the responsibility of the doctor. It is very early days post surgery and at this stage, your head and scalp is swollen and will have some scabbing and presents quite a different reality to that of pre surgery. Hopefully this presents some of the challenges and initial explanations without going into real specifics or personal details. It is unfortunate that you have these concerns and of course as a clinic it is our intention for all patients to leave the clinic feeling completely satisfied, but such cases are rarely straightforward and there are many emotions during surgery dates, and it would be encouraged to discuss such details with the clinic for better clarity and understanding and to receive some reasoning to avoid any confusion. As said within our communication, you have the full support of the clinic, it is just a few days post surgery and you have much to be positive about over the next 12+ months. I look forward to following up with you.

Thank you for your further update and as the comments would suggest, it is appreciated by the community. Your hair looks great and frames your face beautifully and despite "limited" loss pre surgery, the transformation is clear and very impactful. It was a pleasure to assist and I honestly couldn't be happier for you and wouldn't blame you to move on and never look back or share further updates. In fact I would encourage it! You deserve it! Wishing you the best!

Congratulations @Gatsby You are looking great. What a journey and transformation. Wishing you the best for your upcoming procedure. Happy New Year!

Thanks Melvin The most popular surgery conditions and pricing at the clinic currently include Dr. Kostis assisting with punching and so the majority of the results shared over the past 6-12 months will have been with Dr. Kostis´ participation. I think it is fair to say that any initial interest in BHR Clinic is due to Dr. Bisanga and his 2 decades of documented cases that present excellent results and consistency covering essentially every extent of hair loss and hair characteristics. Therefore to consider surgery only with Dr. Kostis would generally be for the financial motivation. If both doctors were available at the same price point, naturally all interest would be with Dr. Bisanga only and that is quite obvious and understandable. The option of surgery with Dr. Kostis at a more economical price point will be of interest to some individuals and not others and so is a personal choice and as said, budget is a motivation here. Dr. Kostis has worked daily alongside Dr. Bisanga for coming to up to 3 years now and routinely punches on patients who have chosen that option of surgery. Dr. Kostis has also performed surgery exclusively and interest in such surgery has increased significantly over the last 6-12 months and so with further interest and scheduling, we would hope to be able to share more case examples in the near future. Dr. Kostis follows the Bisanga protocols of recipient site making and following the design, direction and depth approach of Dr. Bisanga, as well as a consistent and well planned donor extraction management pattern. As we know an important and influential aspect of FUE surgery is not only the quality and competency of the doctor, but also the team of technicians. Any surgery that is scheduled with Dr. Kostis will be supported by Dr. Bisanga´s technicians who have all been trained personally by Dr. Bisanga with several having been with the clinic for more than a decade. This presents quite a unique situation to have such experienced and highly skilled technicians available at such a price point for a doctor who is making his name in the industry. Dr. Kostis will undoubtedly continue to grow in terms of reputation. The clinic have no intention of planning or pushing the growth of his reputation and as such this will happen organically and therefore will naturally take that little bit longer, but will be very transparent and honest and as a result patients will be more trusting which is inline with the ethics that BHR and Dr. Bisanga are known for. In the meantime and whilst the reputation Dr. Kostis grows, some patients will see opportunity and value whilst others will feel more comfortable in surgery with Dr. Bisanga which is completely understandable. @enson12 Im not sure who your advisor may be at the clinic or the communication that has taken place or if you may have attended consultation, but as you have some questions then those questions would be best directed to your advisor who can then clarify the recommendations of the doctor and answer your questions. I wish you the best.

Looking at the image below, I have added the yellow line from the hairline to the mid scalp area, and then duplicated this exact line. You can see that the duplicated line starting from the mid scalp line actually surpasses the posterior scalp in this photo, showing that the frontal restoration covers slightly more than half of the length (front to back) of the top of the scalp (of course we are looking at a photo and can not accurately understand the scalp curvature or bone structure). Depending on final hairline design and placement, 3000 grafts would normally present a complete frontal third restoration, but not a frontal half at required density. This patients native density was around 80FU/cm2 which is above average. His hair thickness was "fine", so to be able to achieve the appropriate illusion of density, a particular density was required in placing. Less grafts could have been used, but then this would have presented a lesser illusion and a lesser visual of naturalness and perceived homogenous density and certainly would not have been able to reinforce thinning areas such as the deeper temple recession, which would have meant a lesser result and potentially needing to return to reinforce the recession in the future.

Always good to have a regimen of medication in place as hair loss is progressive and despite what some of us may want to believe, loss can and will evolve until our final days. This patient will be 40 next year and so based on his pre operative images had actually retained a good amount of hair for his age, but medication would certainly help to stabilise over the longer term as is always the case.

I can understand whilst "on the surface" and at first glance that this may appear as a higher graft count, but this is really where genuine understanding and education regarding hair restoration surgery and achieving consistently excellent results comes into play. It is important to "scratch beyond the surface" and really examine facial/scalp markers to have any real understanding of the realities of the case. If you look at the above image, you can see that the hairline and those initial cms alone are being completely rebuilt from essentially zero. Whilst the patient has some weaker native hairs still in place and so it does not appear as though the hairline is being "lowered", restoration can not rely on these hairs neither for illusion of density nor for any longevity and so the approach taken in such a restoration is to rebuild as if these hairs are not present. Therefore this is a reasonable surface of essentially bare scalp. The first mms alone will have required in the region of 500 grafts as is detailed by the doctor in a previous video for another case - Additionally the temple recession is much deeper than appreciated and much deeper than the standard frontal third restoration. If you look at the following image, and as you can see with the line from the back of one ear, to the back of the other ear, this is deep into the mid scalp and grafts placed into the areas of temple recession and amongst native hair to reinforce are almost in line with the marker. It may not be completely obvious in the photo, but if you with your hands find the back for your ear and then follow that line onto the top of your head, you will feel how far back this point is from the hairline and how close to the vertex. Not to mention that the patient naturally has fine hair and therefore placing must be uniquely appropriate to his personal characteristics in order to be able to achieve the result that the patient has.

The patient wanted to treat his recession and re-establish a hairline. This was achieved by shaving and working back into his frontal third. He is in his late 30s. Here we have the development showed as 2,5 and 8 months and the patient will endeavour to provide through to the 12-month period. Needless to say, he is already happy with the outcome so far and can expect more to come. The intricacy and cleanness of the work can be seen here in both donor and recipient as is our signature at BHR Clinic. Graft Breakdown:- 1s = 453 (453) 2s = 1511 (3022) 3s = 855 (2565) 4s = 39 (156) Total:- 2858/6196 - 2.16 Average. Video: Pre Surgery Post Surgery 2 Months 5 Months 8 Months

@uk005801 This is very impressive at such an early stage and considering the scalp is non virgin and the donor had already provided quite a graft count prior to surgery, so therefore hair groupings will have been influenced. Im very pleased to see the update. Looking very promising and I look forward to the next months.

@cg90 Great write up and documentation of your journey over the last years and your experience throughout your surgery days. No doubt this will really help other individuals in the community who are in a similar position to yourself and considering surgery. I know that there was some anxiety so well done for persevering and with the added factors of not having travelled abroad alone previously, there was always going to be extra nerves associated with that, but I have no doubt 12 months from now looking back, it will all prove well worth it. Great that you didn't feel that the numbing injections were as bad as you were expecting and 4/10 would suggest a good pain threshold. It will certainly be good to refer patients with concerns regarding injections to this thread to read over this specific to help reassure them. I should have access to your clinic photos in the next day or so, so will be sure to share them with you. We always recommend to keep them saved where you can access them easily, because they can be an important and valuable source to be able to check back and compare your evolution through growth stages and to be able to compare photos. Based on our communication and this thread, I know that you have some solid photos to revert back to already. Now patience is key as the next weeks and months will likely experience shedding and then further down time before growth begins to show. Im surprised to hear that I you have not received my emails. If you could maybe check your spam folder for me. As you stated in one of your emails, you could see that my email address had changed. The clinic changed servers and I took this opportunity to change over to a more simple @bhrclinic.com email address, but all emails to my previous address are automatically forwarded to my new address and emails that I have received have been promptly responded to. Most recent email dates are as follows - I received an email from you on Monday 14th AM to which I replied that afternoon in the PM This should have been received as you sent a further email on the 14th, to which I replied again on the same date - the 14th. I then received an email from you last Thursday 17th, and replied the following day on Friday 18th. I have yet to receive any further correspondence. If you have not received these emails, then by all means DM me and I will share images and screenshots showing content and dates, but if they are not in your inbox, then I imagine that they must be in your spam folder. If you could please check and confirm, that would be great. We need to solve any communication issue to allow us to support over the next 12+ months. Again, great write up and I look forward to your further updates. Thanks Ian

@vDk Great to see your images that you have kindly shared. Congratulations on your recent surgery and a great example of the importance in communication between patient and doctor in regards to satisfying the patients desires, whilst respecting all of the necessary considerations in terms of facial shape, donor quality, progressive loss etc. Im very pleased for you and wish you all of the best in regard to your healing and onward growth over the next months. In terms of patients of Dr. Bisanga, I would suggest that amongst all clinics, BHR patients represent quite a large percentage of patient posted results on this forum. Some of these may have required temple point restoration and others potentially not. The percentage of patients that actually share their images and their case publicly is really quite low and this appears to be the case more than ever with the pressures of social media and potentially being recognised and is not really a fair reflection in regard to specific case types. If you are able to share who you may have contacted and a rough idea as to when then I will be able to look into this for you. Off the top of my head here are a few examples of cases where temple point restoration was performed. I appreciate that they are not all patient posted but as with any clinic, the decision to share images is that of their patient and in the situation where a patient may be happy to share his image but not motivated to post them himself, then naturally the clinic will share.

Patient with fine blond hair wanted to re-design from hair line and place into the frontal third and also into the crown that had a double swirl.The surgery was achieved with 3001 grafts as detailed below.The patient came to the clinic for check-ups at month 7 and month 14.1s FU - 3522s FU - 16943s FU - 7994s FU - 156TOTAL 3001 PRE-SURGERY DESIGN POST SURGERY 7 MONTHS 14 MONTHS COMPARISON WET AND DRY

Thank you for you update @Jonulous Things are really taking shape and I couldn't be happier for you. You are doing an excellent job of documenting your journey and progress which is always greatly appreciated and will no doubt be a great help to many and the community in general. As has been said, a few of the recent photo and video updates have been underneath very harsh lighting conditions and even at this early stage, your result already looks completely natural. Im looking forward to your further updates over the next months.

@Whipaway Of course we are in contact privately, but I also wanted to congratulate you publicly. At this early stage, your hair is looking phenomenal. The sound of the brush on the hair in that video really says a lot. It has been a pleasure to assist throughout and obviously we have some way to go yet, but you are a great guy and I genuinely couldn't be happier for you. Thank you also for your kind words.

@andrewfaliro Congratulations on completing your recent surgery. I am excited for the next 12 months ahead. Much to look forward to. I would agree with some of the other comments regarding improvement achieved through treatment of oral minoxidil and this is a great example of the importance and impact of medication. In general, your hair quality is good and you had retained a good amount of hair at your age and so many may have preferred not to consider meds because they may deem it unnecessary, but this shows the impact that it can have and shows how medication and surgery can supplement one another. Design looks great. The surface area of restoration is more than meets the eye. If you look at the depth of the restoration in the laterals to reinforce thinning in and behind the temple, this transitions back behind the temple point and inline with the front of the ear which is into the mid scalp and so graft count based on surface area is not actually particularly high and based on the quality of native hair behind, any lesser density in the hairline would have presented a weaker density than native hair behind. As you know these initial months can feel as though they may pass slowly as you are awaiting growth to occur and so patience is key, but come next summer you will be feeling quite differently about your hair. Heal well.

Hi @mrmane85 Thanks for your question. As you ask regarding this particular case, without providing any personal details, based on the posters own disclosure of many previous strips and a small FUE totalling around 8500 grafts, and the requirement to revisit previous areas that achieved unsatisfied results, it is considered a repair surgery. As discussed, this is a very different and more complicated and challenging case than other enquiries that may present a virgin scalp for example, and therefore in this instance, surgical options are only available with Dr. Bisanga.

Wishing you the best Christopher! You have come a long way already and will be great to follow your continued progress.

Thank you for your interest. The patient didn’t have any concern with the scar and therefore it wasn’t discussed in any surgical approach.

Thank you to the patient for providing these updates as just over 6 months. The goal was to re-establish his hairline and work back into the frontal third as needed and connect to the temples. A conservative approach was taken and even early on this has given the patient a dramatic change and styling options. Strategic placing was used in the deployment of grafts are per usual and already a nice result has been achieved with an extraction pattern that was spread throughout the donor required to present as little impact on the donor as possible. The patient will endeavour to also update to the 12 month period and we will post accordingly. FOLLICULAR UNIT MAKE UP/HAIRS 1s 416/416 2s 1624/3248 3s 656/1968 Total: 2969/5632 = 1.8 hairs per graft average. VIDEO PRE-SURGERY HEAD SHAVED POST SURGERY 1 WEEK 2 WEEKS 11 WEEKS 6 MONTHS [img]

Thank you @New_Barnet_Please This is a great one year review post and you have really documented your journey, both with great images and descriptively, very well and I have certainly enjoyed following your evolution and progress. You look great and both myself, the doctor and all of the BHR team are extremely happy for you. We all appreciate your dedication to your thread because I know that when growth occurs and your desired outcome has been achieved, life gets busy and quite often, understandably there are other priorities. But patient posted experiences and results are the most well received and valuable for obvious reasons and so no doubt there are many who have really benefitted from your thread. It is really positive to hear that you have responded so well to oral minoxidil and that your crown has also benefitted. This really puts you in a strong place looking forward. It was a pleasure to coordinate your surgery and for me, the increase in confidence is often a game changer that then flows over into many aspects of life so Im very happy to read this. Enjoy every minute.