Raphael84

It seems the confusion over DHI and FUE is still raging, partly due to marketing and furthermore by naivety in the industry for those navigating the minefield of hair restoration and unfortunately are easily blinded by the terminology. In this brief video Dr. Bisanga, Dr. Kostis and HTN´s Melvin discuss this exact question asked during a recent Instagram live session.

Thanks Melvin

Hi @Whipaway

As the clinic moved location at the beginning of January 2020, the new location is around 12km to the south of Brussels city centre in an area called Waterloo.
If you have already received the document provided by the clinic in relation to nearby accommodation, you will see 4 options that are listed and their distance from the clinic.

I have personally stayed at both the Ibis and Value Stay. Both present basic yet standard rooms, but for a 2 night stay (depending on how long you intend to stay in Brussels) both were fine. The "beauty" with the Value Stay hotel is that it is 200 metres from the clinic and so ideal for getting to the clinic and back for pre op, surgery and post op without the need to organise a taxi or an Uber for example.

When I stayed at Value Stay, I reserved a larger room with kitchen appliances to be able to prepare my own food as I stayed in Brussels for a week and they generally have bath as opposed to only a shower so whilst not luxurious, it was comfortable and of a decent size. I have not stayed in a standard room at Value Stay so am not sure but many patients utilise this option and most find it satisfactory. 

The Ibis room was small and requires transport as is between 4-5km and of the two, personally my experience in Value Stay with a larger room was more recommendable.

For those with higher expectations and specifics, then the other two options on the clinic document show the Cote Vert and Martin´s Grand Hotel which offer much more comfort and are of a higher standard and therefore this is represented in pricing. I will choose one of these next time I am in Brussels to be able to offer further insight regarding these options.

All patients have their own preferences in regards to what they personally "require" and expect from accommodation so whilst for most, it is about convenience due to having such a brief stay and limited time actually in the hotel, others may feel that having spent x thousand Euros for surgery, they deserve a little luxury and more comfort.

Best of luck with your decision.

The patient wanted to address his recession and work back into the diffused loss area. Both Dr. Bisanga and Dr. Kostis shared the surgery in terms of the graft punching and Dr. Bisanga cut the recipient sites on this case.

Patient Quote at 6 months:-
"All is good, the hair is growing faster than expected. Already I feel happy about the results and there is still time for the final result."

MEDICATION:- Finasteride

DENSITY:- 70/80/90

GRAFT/HAIR BREAKDOWN:-
1s 553/553
2s 1861/3722
3s 974/2922
4s 112/448

TOTAL:  3500/7654, average hairs per FU = 2.18

VIDEO:-

PRE-SURGERY

POST SURGERY

8 MONTHS

COMPARISONS

There is much confusion regarding various techniques within FUE surgery and which tools may be optimal and it would appear that common conversation has now transitioned from the ever popular "manual or motorised punch" to direct hair implantation/stick and place or pre made sites and magical tools such as "sapphire" blades. 

In each of Dr. Bisanga´s last instagram sessions with Melvin, when taking questions from viewers, questions related to DHI/stick and place have been asked and there is a general lack of understanding of what this is and marketing has undoubtedly impacted the field, often dishonestly.

An excellent article written by my colleague Stephen address some of these doubts -

Pre-made or Stick and place? What is best? Let's get rid of some of the jargon and marketing and look at the facts!

Anyone who has spent time in this industry will know that if you can't base your reputation on solid and consistent FUE results, then you need adapt to attract, this means usually you up the marketing and down the graft costs to be able to survive. We all need a USP or a unique selling point and this will be usually dependent upon what you are good at or not so good at. As the saying goes, behind large marketing campaigns you find small doctors, and what I mean by that is that due to a lack of real genuine and consistent results, many clinics will never be able to attract the punter by what happens in the surgery room, so in essence fall back on marketing a special “technique” or indeed the tools themselves will be weaponised to attract, or for some, a low price that is not short on promises!

With everything from a 30 years guarantee on the hair transplant, similar to what you would expect on double glazing or white goods for the kitchen, to the best price or the best techniques, painless surgery and even freezing the grafts or using some magical holding solution, nothing really is off the table. What lacks in medical ability is certainly alive and well in other departments and the sad thing is, yes you guessed it, it works, if it didn’t, they wouldn’t do it.

So, with this in mind, how the graft is placed can become a minefield of conflicting information and even contradictory in its claims. Some of it is educational and valid and some marketing glitz, designed to bamboozle the reader and give them a sense that there is science in the claims and this transmits to a better result and therefore a benefit to the patient.

So, what do we use at BHR Clinic and why?

Dr.Bisanga and many top hair transplant practitioners will use pre-made slits. Don't let the term "pre-made", fool you to think of a pre-made sandwich or a suit or something inferior to "bespoke", because in this sense it does not mean the lack or the inferiority that this term may imply.

It also has nothing to do with the harvesting of the grafts or the time they are out of the body, it is more concentrated on the timescales from the recipient sites being made to the placing of the graft into the sites.

Dr.Bisanga will once the donor has been numbed and grafts punched, will start then to numb the recipient area and cut the sites needed for surgery, or a good proportion of them in one go. This for him is critical in giving that flow and design he knows will be needed for the result both he and the patient are looking for.

Every site cut will be in light of the previous one and in view of the next one, and will give the design, density, depth and direction that will eventually bring about the final result. For Dr.Bisanga it is like laying out the chairs for the audience to sit on, it is easier to lay them all out to the designs you want prior to occupation and then fill them, rather than place one chair, one person, one chair, one person, one chair, one person..or as we say, rinse and repeat. So, the analogy may not be perfect in all detail but you get the point! Once Dr.Bisanga starts the sites he is in the zone and the momentum and all has kicked in and he knows where he wants that next graft to be and therefore the site also. He has magnification, his field of vision is small yet enhanced and he has that one after the other cut coming in rhythm, and really is like a precise machine in this, a constant flow without a continual stop/start . It is clean work, precise custom made blades are used and hair angles and flows re-created.

Once completed then the technicians will place the follicular units into these sites, their work is to handle the graft well, hold it above the bulb gently and place it into the sites with little to no trauma. The depth and direction etc is not down to them to create, they follow the path already made and either with forceps or the KEEP implanter, these sites will be opened and the graft gently inserted.

This is our system, it works perfectly well and we have no incidence of pitting or ridging or indeed problematic patient healing. The opposite is true and we have also many cases of fast growth, it has been like many aspects, honed throughout the years but not substantially changed.

Step up stick and place..the site is cut and the graft is placed, the site is cut, the graft is placed, the site is cut and the..okay, you get the idea..The cycle changes, it is not cut, cut, cut, but cut and place, cut and place, stick and place in this instance. Some will prefer this, and also some top surgeons’s will prefer it, this is the two-stepped version of this technique, but for us the setbacks are then you are interrupted from cutting the sites in that rhythm and knowing instinctively where the next one will be, to a kind of start - stop routine. Okay, it may work for some, good on them and this is not a criticism of the technique per se, but most, and certainly Dr.Bisanga and Dr.Kostis, will prefer the continuous flow of cutting the sites to get that design needed. A valid question here however, is who is cutting the sites? Is the doctor entering the scene to cut them and place himself or is it he cuts and tech places, he cuts and tech places, and again? A question worth asking. So it is this constant back and forth or it is the doctor themself doing all? If you want this method then ask the doctor the logistics of it and how they will do this and what are the time implications also on it and especially for larger surgery? This is the two-step stick and place in a summary not exhaustive explanation.

One step stick and place, the implanter also cuts the site needed in the same action. A question for those who want this is are they happy for the technicians to do this? Remember the sites give the design, depth, direction, density etc, you will need smaller ones for the immediate hairline and larger for the higher groupings, but need to be aware, it is probably a group of technicians doing this. Do they understand the intricacies needed? Will the left handed tech cut the sites the same as a right handed one? There is no design for them to follow, so it is CAYG, or cut as you go, so make sure you understand the implications, this is usually more tech centric as a rule, find out the detail and see who does this. If doctor only, then the whole process is then doctor centric and not tech centric, what are the implications on the time needed for this surgery to be completed, does it need more injections to keep the scalp numb as the site cutting time is largely extended? One should understand all of the factors and implications behind a simple tag line of stick and place or whatever a clinic wishes to call it

So, without giving an exhaustive, in-depth assessment of all of the techniques, I have sought to give a hint, a scintilla an overview of things to consider and ask your chosen clinic. As said, you may favour one technique over the other and that is fine, but it is good to ponder things that possibly you were not aware of, beyond the term of pre-made or stick and place and some of the implications.

Take care and thanks for reading, I do hope it was of interest and will be beneficial to you!

Steve

@J123m

Congratulations again for completing your surgery. I am very pleased and excited for you.

Thank you for the mention. To be honest, it has been an extremely pleasant and straightforward process with yourself. From first contact, to our zoom call and then moving forward with confirming your surgery date, you have been transparent, efficient and a generally great guy so big thanks to you too.

Great to hear that you are very pleased with your hairline and the agreed design. If you look at the space and distribution of your extraction pattern, your donor will heal immaculately and you will have no idea that 2400 grafts have been extracted.

Surgery days can be quite long and being in the chair all day isn't the most enjoyable of days, but the rewards and results are always well worth it and that part has now passed.

I know you had some pre op nerves and anxiety which is completely normal and expected and I hope that I was able to put you at ease to some degree.

Great that you were able to get a good nights sleep as this can be the challenge for many which can then be compounded from one day to the next, so hopefully this has continued.

Looking forward to your further updates.

Heal well.

@LeBerry

Thank you for your update. Your hair is looking fantastic and already very natural.
In regard to hair structure and maturation, I am recently just past the 12 month stage and I have noticed that some hairs have only just settled in these last weeks/months. so as you have said with another 6 months until the 12 month stage, this will evolve and calm. 
Some patients require a little longer and a few hair cycles will still present change in such structure.

It is great to see that already at this stage your result has surpassed your expectations.

Genuinely thrilled for you.

Dr. Kostis has been an integral part of the BHR Clinic team since 2019 and working exclusively alongside Dr .Bisanga has enabled him to hone his skills throughout a 2.5 years intensive period of hands-on FUE.

Dr. Kostis has learnt the "Bisanga" Protocols starting from the in-depth consultation to the planning and execution of surgery, including the now famous "Bisanga" extraction patterns and approach, to the cutting of recipient sites with small custom made blades to the holding and placing of grafts using forceps or with the KEEP implanter.

Dr. Kostis in a proficient #FUE surgeon in his own right and has also been trained in body hair usage of beard, chest and even leg hair subject to the right criteria.

You can expect the Bisanga quality to echo through in his surgery with also the signature of Dr. Kostis, and his entire approach and process capitalises on two decades of the elite experience of Dr. Bisanga that has been imparted to him in this accelerated and exhaustive period.

From artistic design to optimal clean extractions, you can be assured you are in the best of hands with Dr. Kostis.

@shiba1985

Sorry if you may have had an issue with playing the video. It seems to have possibly been a temporary glitch as it does appear to be working fine when I and others have checked.

The follicular unit for scalp will traditionally also contain the sebaceous glands as part of the structure and be kept in-tact. The difference with what we call "wet" hair, are the then associated apocrine glands that are also larger in size and will not need to be transplanted with the follicle structure as such.

As we see body hair FUE performed much more commonly and become a great tool for patients with extensive loss and/or donor limitations, it is natural for individuals to seek even more potential sources for restoration.

With the standard and more reliable body source being from the beard, the chest is then generally the next consideration.

Dr. Bisanga, Dr. Kostis and Melvin discuss the potential usage of "wet" hair for restoration and if it is a wise donor source to use via #FUE?

@Henle88

Thank you for posting your case and your experience. The design and quality of the work shown is clear, although understandably based on your thread and details, there is some justifiable confusion.

As I personally do not know your case or we have not had any previous communication, I have no knowledge of correspondence or surgery details and so therefore I would advise to follow up with your patient advisor for any clarification.

In regard to more general questions about pricing structure and surgery conditions, the clinic have implemented some changes in recent months.

As standard, FUE surgery at BHR Clinic will now see punching of extraction sites shared between both Dr. Bisanga and Dr. Kostis.

Dr. Bisanga has the upmost respect for the ability of Dr. Kostis, and Dr. Kostis has shown at a recent hair restoration conference amongst doctors where live surgery is performed, that the quality of his punching is optimal and in line with the most highly regarded doctors in the industry.

Dr. Bisanga has worked incredibly hard to forge his reputation over the last 15-20 years and as members of the forum will now that BHR is renown for being one of the most ethical and honest clinics today.

With that being said, the above surgery conditions are outlined and clearly explained to any individuals who present their interest in surgery with Dr. Bisanga. 
Obviously patients who confirmed surgery prior to the change in pricing and therefore previously agreed conditions are being honoured and surgery is proceeding as agreed.
There was naturally a "change over" and transitional period of where some patients will have scheduled based on previous pricing and surgery conditions, and others the more newly introduced changes.

Dr. Bisanga is still available to perform surgery exclusively in terms of making all recipient sites and punching all extraction sites, but as said, this is at a new price point.

I can clarify that this change has not been introduced to allow scheduling of more patients each day which I can confirm does not occur. The objectives of the clinic are not to increase quantity of patients. This is reinforced by the amount of enquiries that we refer to consultation before considering any surgical intervention.

One of the motivations for such a change, in addition to the ability of Dr. Kostis, is the fact that many individuals who are serious to proceed with surgery have budget constraints which is completely understandable. Moving forward, having such flexibility will present more economical options for quality surgery.

I can only apologise in regard to any confusion in this instance and as said I do not know the specifics of this case or the reasoning behind it, but hopefully this helps to explain some of the changes in structure and clarifies things moving forward. 

@New_Barnet_Please

I hope you are keeping safe and well.
As you have reached the 6 months stage, it would be great to see how things have progressed in the last months whenever you may be able to provide an update.
Wishing you the best.

16 hours ago, Viney said:

May I ask which doctor did the donor extraction?

This particular case saw Dr. Bisanga perform all punching for donor extractions.

We are currently in the process of preparing a video to share in the next weeks regarding BHR punching protocols and showing examples of work from both Dr. Bisanga and Dr. Kostis which should be a very nice addition to the recent content that we have published and so please do keep an eye out for that.
When it is complete and ready to share I will be sure to post a thread link here. 

It is great that the community and individuals in general are beginning to understand the importance of an optimally managed donor extraction pattern and really paying attention to this.
Oftentimes results may be presented without any images of the donor area post surgery, or perhaps the entirety of the graft count being extracted in a very focused area in the back occipital region.
Not only is this the richest area of the donor with higher hair groupings and more robust follicles, that any long term approach will manage conservatively due to the potential requirement to utilise this area in future surgery and really capitalise on the more favourable hair groupings in the mid scalp and crown where placing density will be lower, but to create the most natural hairline, mother natures most soft and single follicles should be "cherry picked" from donor areas that naturally provide this hair type which is more commonly found around the ears.

So much press/social media related to hair restoration focus purely on aggressive and "desirable" hairline restoration at high density, regardless of if this may be appropriate for the patient or not. The richer donor area is overworked to attain higher hair groupings to maximise the illusion of density and therefore extraction protocols are not efficient or in the best interest of the patient. Oftentimes the patient will realise this the hard way when they return for further surgery due to progressive loss behind the hairline or in the crown and they simply no longer have the donor capabilities to meet the demand.

3 hours ago, Melvin- Moderator said:

These photos are shared by the patient. So it’s difficult to get the best quality. If the patient returns to the clinic, then obviously it will be better quality.

Exactly this Melvin.

Ideally we would be able to present a recorded video of each patient result, brushing through and parting their hair etc. The challenge we have at BHR much like some other clinics, is that we are an international clinic. A very minor percentage of our patients actually reside in Belgium and therefore depending on the patients location, it is not convenient nor feasible for the patient to return for photos/videos post op.
Oftentimes as can be seen on this forum and various threads, it can be extremely frustrating for the individual to be advised that they would need to travel for consultation prior to confirming surgery, so the challenge of them potentially returning for photos is very unlikely in most cases.

Many other clinics such as within Spain for example, work predominantly with a domestic patient, meaning inviting the patient back is much more feasible.

Regardless, we intend to share as many cases as possible where the patient is comfortable to share their photos and present their case, giving back to the community and we are very grateful to those that kindly do so.

With that being said, sometimes photo quality may not be optimal, but the transformation and result is clear and the quality and naturalness of the procedure is evident and therefore it adds value and has a place on the community forum.

Thank you for the support and comments.

DENSITY:- (FU/cm2) - 60/85 (Average 72.5)

 

7 hours ago, JoeMan said:

also think Dr. Bisanga has some involvement in an Athens clinic where he's training other Dr's. When I was looking, this was a slightly cheaper option but I'm not sure what the rate was or if he's still doing this. 

Dr. Bisanga is no longer personally performing or involved in surgery in BHR Athens. 

For those who may have a tighter budget or are looking for more economical options, Dr. Kostis is available in Brussels.

Dr. Bisanga and Dr. Kostis explain to Melvin the importance of selecting the necessary fine single hair follicular units for a refined and natural hair line.

Yes it takes time, the harvesting is harder and more delicate, but there are really many reasons why you need to get this right first time!

Thank you for the update. Looking great at only 4 months and the next months will show a very nice improvement as hairs mature and settle.
Very pleased for you.

You really have come a long way in only 4 months. It is easy to forget at times, especially when you are see the slow progression on a daily basis.

The following comparison presents things quite well -

@Marco Van Basten

Thank you for the update. You are looking great at 4 months and right on track for an exciting journey over the next several months. At 4 months things are beginning to take shape and you will see new growth, increased density and maturation over the next several months.

To thank you for a very nice photo quality also. Very consistent and honest and transparent which is always much appreciated from the community.

Im very much looking forward to the next months for you and please do continue to keep us updated.

On 2/14/2022 at 11:31 AM, LeBerry said:

Honestly, if this would have been the final result, I would have already been satisfied

Congratulations on such impressive early growth @LeBerry

You are looking great and able to maintain your hair short both in your donor and recipient and the natural result at such an early stage is impressive and your above quote really says it all!

Due to great feedback and interest, we have put together a video presentation of your journey so thank you so much for documenting and sharing your photos so consistently up until now, and things will only get better!

4 hours ago, ConnorCrosby said:

Hey man! What are your/the clinic's recommendations in regards to hair wax and hairspray?

In regard to such products being used on native hair amongst/behind your transplant post surgery, the concern when using hair spray is that it is not only the hair that is receiving it. Hair spray can get on and stick to the scalp and especially those of us that have concern with loss, generally use a little more than we should to help us conceal. With that being said, hair spray and any other such highly chemical based products should not be used on the head for absolute minimum of one month post surgery, ideally longer as they are not assisting the scalp environment which we naturally want to keep as optimal as possible post surgery.

Hair wax that can be applied from the fingers directly onto the hair presents a different situation as the scalp itself can be avoided.

in terms of using product on transplanted hair once growth occurs, you will be several months post surgery by the time you may feel that products are necessary to use and at that stage initial healing will have long passed and you can consider other products. 

Hair spray in general is never a healthy choice for the hair or scalp.

Concealer is a big no post surgery as again, the tendency is generally to always use "just that little bit more" and whilst designed for the fibres to attach to hair shafts, more often than not concealer will sit on the scalp. Of course many patients post surgery are looking to conceal their procedure and therefore may be considering such products but just like hair spray, concealers are never "healthy" for the scalp and in the case of concealers, absolute minimum of 3 months post surgery before considering usage.

There is a scourge that is causing untold misery to countless victims through the use of hair extensions and relaxers, that inevitably will cause them to lose hair.

The pursuit of what is deemed beauty can be very costly and we see it with emails daily and the destruction it causes. Here Dr. Bisanga describes some of the pitfalls and how to avoid them!

No wonder this got well over 135k plus views on our French channel in a matter of days and much exposure in the French press.

A hairline can be a blessing to roll back the years, or a curse that you will forever regret!

Presenting Bitesize with Bitesize, #47 - Allow Dr. Bisanga to explain some of the common pitfalls in hairline design that you can live to regret. Remember hair loss IS progressive so you need to be wise and personal  in your approach and not consider a "YES" clinic, or the brief joy can be outlasted with long term regret.

Get it right first time and listen to the experts who have decades of experience in designing a unique hairline that compliments your face shape and bone structure whilst optimally planning based on your donor resources.

Continue your education with "Designing a natural hairline" -

I understand the challenges in place and travelling for consultation may not be easy or even feasible for some depending on location and their situation.

Hair restoration and its approach is not an exact science and as such is subjective. As said above, all doctors and clinics will have their own protocols and preferred approach and as we see on this very forum, approaches and design can differ quite dramatically which is one of the main motivations for individuals to have interest and preferences for one doctor over another.

Dr. Bisanga and every other doctor would all proceed with surgery with their own artistic vision. We see this not only in hairline design, but also in donor extraction management. This also applies to what they may perceive as limitations, "safe" donor area and graft availability etc.

Each doctor will have their own "markers" and their own "specifics" that they may assess and measure to determine candidacy. There is no industry standard or set protocols / "check list" for this and that applies even more so for repair patients.

Repair patients and their hair situation and status are all very unique depending on their history and previous surgery and repair in general can present very delicate challenges. It is down to thorough and ethical practices that Dr. Bisanga would require to assess repair patients in-person himself to be able to understand the patient´s case and based on those findings, have an in-depth conversation personally with the patient explaining any and all concerns and challenges.

If candidacy is possible, this then allows the patient to have been thoroughly informed of any limitations and allows Dr. Bisanga to honestly and transparently explain what he feels may be achievable. It allows Dr. Bisanga to explain that growth can not be guaranteed for example which is the case and protocol in repair surgery and to ensure that the patient has realistic expectations and understands the potential limitations in place. This is a very important part of the process to avoid disappointment or confusion at a later stage when surgery may have already have taken place.

Each doctor will not only conduct their consultation and assessment uniquely, they will also explain their summary uniquely and make unique recommendations and this therefore explains why consultations with different doctors presents different experiences and is another reason why patients will make their final decision on their preferred physician. They get a feel for the doctor´s personality and if they are a good fit.

The clinic appreciate the potential challenges with travel and this is why Dr. Bisanga offers international consultations, to be as accessible as possible to individuals who present interest in surgery with him. Dr. Bisanga offers consultation in the US each year, just as he does in the UK and many other locations. He is one of the most travelled doctors and performs consultation himself as opposed to non medical staff or non doctor. 

Any such requirement for in-person consultation is always a medical decision made in the best long term interests of the patient as opposed to a business or financial motivation.

If the industry standard were to be more thorough in assessment and requirement of in-person consultation when necessary, the amount of repair surgery or poor results would be much less as a result. As an industry we must improve to protect patients and make decisions based on their well-being.

@Gatsby

Great write up and I am wishing you the very best my friend.
You are a credit and great value to this community and thoroughly deserve the best result possible.

I look forward to following your evolution.

Take care and heal well.