JoeTillman

John, I can appreciate your points about the scarring but I think that you are misrepresenting the reality of your case and how it may or may not apply to others. Maybe it's because I've got more experience with this issue or maybe I'm just being more honest than the casual observing member, but I see a lot of scarring in your photo. Is it as obvious as a linear scar? Of course not, but it is there nonetheless and I see two issues. 1.) The dots are obvious to me. Even with the low light and lack of contrast and focus I can see them. 2.) The confluence of scarring is more obvious. I can see the areas between hairs that have more normal skin tone and then the splotches of scarring as evidenced by the lighter tones. I know the point is to sell surgeries for Dr. Vories since you are now the representative for him (congratulations by the way) but it is precisely because of posts like yours that I continue to receive emails from patients that feel they were duped because they were told by their respective doctors that they will have no visible scarring so they can shave as short as they wish or they deduced that this would be the case because of the multiple posts like this one where the poster says "no visible scarring" while their head is shaved. The photos almost always tell a story different than that of reality and I can clearly see in your photo that this is one such case. Regarding your last photo that is used to show your donor thinning, or lack thereof, this too is misleading. I see a strong demarcation between the donor zone on the right side of the images and the temporal zone on the left side of the images. This demarcation is shown as what almost looks like a "line". This is a direct result of having had so many FUE extractions where the pattern was abruptly ended. A feathering of the pattern on both ends of the extraction zone would alleviate this but the image shows that your donor has in fact been thinned. The math would show this obviously but so do your photos. I really like FUE and I love the option that it gives patients. At the same time however I'm a realist and even more so now that I no longer represent the interests of a single clinic I plan to point out the issues that many others gloss over. Any surgery that removes hair from one's head is going to leave visible evidence in some circumstances. Once you're cut, you're cut and this means that your head will never be the same, FUT and FUE alike.

This is a nice example of mature temple angle closure. Well done to Dr. Arocha and his team and congratulations to the patient.

I think that Dr. Konior's patients and those that have spent time investigating his practice may feel he is a specialist in FUE as they may have seen results or spoken to patients outside of the online forums. For instance, I had no idea he's performed FUE for ten years but if that is the case, why are there so few results shown online? Perhaps I overlooked it but I cannot find a single FUE result on his website. Dr. Rahal's website doesn't have a large emphasis on FUE either but there are several results and of course I've seen many more during my time with the company so I am privy to that but I think that if Dr. Konior is to be considered a specialist in FUE there should be at least some semblance of a push to get the results out to the public. About a year ago someone asked if anyone could point out FUE results by Konior, After five pages not a single result was posted or discussed.

You gave a good writeup and I wish you well for your recovery. Remember, the waiting is much tougher than the surgery so don't get bummed out while you wait for your results. They will come, you just have to give it the time it deserves to materialize. The experience you had during your visit is no surprise, they have a top reputation for a reason.

Looks very nice. Congratulations to you and to Dr. Cooley and his team.

Got it, thanks for clarifying.

Well, you can get up to stretch your legs during the procedure. You'll also get a lunch break and of course bathroom breaks. Hopefully the techs will be personable so chatting with them may also make the time go by faster. Always remember, it's just one day then the real wait will begin:) Btw, whom are you flying from NY to see in San Francisco?

Time is one factor but it is also because clinics often need to move the patient and if they are sedated it is problematic and in some cases downright impossible. Lack of sedation also allows the patient to have more of a contribution to the procedure as they can ask for adjustments and fine tuning during the procedure. If performed properly there is absolutely no need for sedation, especially with FUE.

1) On the high end there are 15% of the donor hairs in telogen. What most people do not understand is that telogen does not occur only to single hair follicles. If it did then you are looking at, on the high end, 15% of the 25% that singles take up out of the whole picture. So say you have a 4000 graft strip, where 25% are singles. That is 1000 grafts. 15% of 1000 is 150 so IF all telogen hairs were singles then you'd have 150 hairs gone with a bare spot in place of the hair, free to be destroyed by the passing blade. However, telogen occurs to singles and to multi-hair units alike and you don't always have all hairs in a follicular unit disappearing into telogen at the same time. Sometimes you will have one out of three, or even two out of three so there is still a hair in the spot thus allowing the practitioner the option of avoiding it. Furthermore, hair shafts do not always shed when they are in full telogen. Sometimes it takes the new hair from anagen to push out the old hair shaft that preceded it so this means that just because a hair may be in telogen the hair shaft isn't necessarily going to be missing with a bare spot in it's place The above reasoning means that the overall kill rate due to telogen is lower than what some will have you believe. When you're dealing with 4000 grafts in a properly removed donor strip you are looking at an extremely minor kill rate that has zero impact on the final outcome. On the surface, it makes sense to say that all of the these hairs in telogen have the potential to be forever destroyed but when you dig deeper with the facts then the final impact is seen to be much lower. 2) When a donor strip is properly removed, the doctor will use tumescense to inflate the donor zone. This does two things. A) When the scalp is tumesced the skin is spread apart thereby making the spaces in between the FU bundles much greater and easier to navigate safely. B) When the scalp is tumesced the internal pressures are greatly increased as is the lateral pulling pressure of the skin. Think of pulling a piece of latex apart with both hands. A good doctor will not just dive in and start cutting. He will use the edge of the scalpel to score the top of the skin. This makes the wound open up so that the visibility into the tissue is obvious. The more light scoring is done the more the tissue widens and separates. This is one reason why Dr. Haber's blunt donor excision works without a sharp blade. As the wound opens the doctor can see which direction the hair shaft takes and avoid it. He can already push the scalp in between the bundles as seen from the top so as the wound opens it confirms his assumptions or contradicts and he can make adjustments as is necessary. f the doctor shows the patient one side to demonstrate the lack of transection, what makes you think that the other side is the complete opposite? What is the logic to say that one side is done perfectly while the other is bad enough to hide from the patient?

I don't understand how FUT is best for the surgeon? Because of his need for techs and he can be less hands on or because you think he is making more money? If the former, then yeah, the doctor can take the strip, make the incisions and then disappear and take a nap in his office. If the latter, then you're mistaken. Less money per graft and much more overhead than with FUE. The economics favor the doctor with FUE. The fatigue factor favors the doctor with FUT. Scar5 Let's not rewrite history here. Yes, FUE was ostracized by the HT community, and I was part of it, but EVERY development that drastically changed the way surgery was performed took a long time to make their way into the mainstream. Plugs turned into strips, yes with an "s", because of the multi-blade scalpels that were used to cut two or three strips at once. This is STILL being done in some clinics. Strips turned into strip (singular) with a single blade scalpel (this took several years) and then there was a big fight when graft dissection went from "eyeballing it" to then using jeweller's loupes for mini/micro grafts and then on to the eventual pinnacle of FUT with microscopes for follicular unit grafting (which took about 10 to 12 years to go mainstream). Strip wasn't accepted overnight and the economic "advantages" don't make sense. Again, larger staff is needed and the cost per graft had to drop. Before strip, plug jobs of a few hundred grafts were still up to 10K dollars or more and this was without a small army of techs (overhead) because there was no follicular dissection to speak of. It was quick and profitable and incredibly damaging to the patient.

Not really. I've had multiple strips from both sides and my last pass with Dr. Wong was ONLY strip from either side. In my case, if I were to have another strip, the sides are the only areas where more can be taken. The back is done. Tightness on the top of the scalp is, as already mentioned, irrelevant when considering strip surgery. However, one thing to consider is that many patients talk about a tightness in the top of the scalp, sometimes accompanied by a burning and/or itching sensation, which seems to be a side effect of hair loss. It isn't universal but I've heard of this a fair bit. Just food for thought.

a) How many grafts seems suitable for me to reconstruct the hairline back to its original form ? We don't know what your original form was so no one can accurate answer this without pre-loss images. However, you can't afford to take your hairline back to where it once was (assuming a juvenile hairline) because you have a lot of loss to address and without medication you are going to have a lot more loss. b) How poor is the density in my midscalp and crown region. How many grafts would I require to alleviate the situation ? It's not too bad. The short length isn't helping matters as it shows more lack of density at such a length. However, I would think that no less than 3500 grafts would be needed for the top, hairline to vertex, not including crown. c) Does my donor area look capable of providing the grafts required ? I think your donor area shows relatively low density but it may have something to do with the lighting/flash used in the pics. Oddly, the density at the occipital ridge and into the nape appears to be higher. If I were you I would not consider any surgery without medication. You simply have too much more to lose and not enough hair to address the future loss, especially in the crown.

You don't need mineral oil exclusively (or any oil or gel for that matter). I used to just stick my head under the shower stream for a few minutes and leave the shampoo on, rinse then repeat. Once I stepped out of the shower I'd take my town and lay it on top of my scalp then pull it forward. The scabs that are ready to come off will. The ones that are not ready will be ready during one of the next attempts. Others have used mineral oil as well as olive oil, vitamin E oil and aloe vera gel. The idea is to apply this to the scalp and let it sit for several minutes to soak in and saturate the scab tissue. It helps to lift the scabs up and they eventually can separate from the recipient site. Once you leave it on for up to half an hour or so you can take your shower and rinse everything off. That said, you should consult with your clinic and follow THEIR guidelines for when and how to remove the scabs. Some clinics feel you shouldn't touch the recipient site for a full month so it just goes to show you that different clinics have different approaches to patient care and how the recovery should be addressed.

Cases like this are unpredictable. As SFGF said, his doctor claims to have seen zero indicators for this type of outcome. Playing devil's advocate, had he seen the issue I'm sure he would have taken measures to avoid such an outcome. When patients are in consultation with doctors (or consultants of doctors) that perform FUT there should be a laxity test where the doctor or consultant literally pulls and/or pushes on the donor zone to see how much vertical movement there is. This is the only way to determine laxity. However, there are cases where the laxity is not what it may seem. The mastoid processes are the two areas at the back of the scalp where tension is normally higher. If you compare the skull to a square box the mastoid processes would be the rear two corners. It is this area where doctors will usually run into challenges with laxity and in RARE situations for even the most experienced FUT doctor these areas will be unusually tight and catch them off guard thereby requiring adjustments to allow for healing via secondary intention (as Blake referenced earlier). This appears to be more serious because it looks like the entire length of the donor wound has been left open, or re-opened. I believe that if this were an issue isolated to one area of above average tension then that area would be the one to have release of tension by allowing the wound to re-open so I'm left a bit confused as to what really may or may not have happened. If this were one isolated area then the rest of the wound could heal as expected leaving a shorter length of the wound in need of eventual revision. In this case, the entire length of the wound will have to be revised which could indicate the tension was more severe over the entirety of the wound. However, the donor scar most likely will not be as wide as the open wound we see in the photos as skin will fill in and the wound will become smaller before permanent scar tissue settles in. I suspect that once everything has healed the appearance will be much more acceptable (but still wider than anyone would wish for). Unfortunately it takes about six months to get to that point and even then it will be another two to four months before a revision should be attempted. It is just sad that

This isn't urgent and you don't need help:) If you expected anything of significance at this point you probably didn't do a lot of research that would have told you not to expect any signs of growth for three to five months. As KO said, if you had anything significant by this time, we'd be surprised. I'm sure your clinic would agree. If it looked like this at six months, then you'd have reason to worry, but not now.

A few observations/questions: 1. How did the patient express that this is a complete failure? Is he saying that nothing grew, the result did not grow enough or is he unhappy with the design and/or degree of lowering? The answer or answers can make all the difference on the legitimacy of his complaint. 2. I see residual redness still in the recipient area which tells me indeed that there is more growth to come. 3. The current situation is, in my opinion, a success based on the number of grafts, patient age and that he had "reasonable expectations" during the consultation. His hair also appears to be fine which further validates the result. His face is framed better and the inconsistency of density and overall hairline shape has been remedied. 4. The documentation is refreshingly consistent with not only lighting and angles but the damp nature of the hair as well. Damp and combed in the befores, damp and combed in the afters. 5. I commend you, Dr. Haber, for posting this case with the full disclosure that the patient is calling this a failure. In fact, I LOVE this about your post because this helps to show that not every success necessary need be super high density or massive coverage.

With regards to the speeding analogy, an expert is an expert when they know why one must slow down and how soon based on the variables associated with differing vehicles and driving conditions. Simply saying one is going too fast is relative and generally easy. An expert would be able to make the statement that one should slow down based on the make, year and model of the vehicle and how the inertial mass will be slowed based on the braking system known to come with the vehicle from the factory and if the braking system is the actual system from the factory to begin with or if it is a third party braking system from Stoptech, Brembo, Wilwood, etc. The tires that are used, weather conditions, crash test ratings as determined by the NHTSA will also help to determine the survivability of a crash if one does not slow down and gets into an accident. An expert would know this from experience dealing with such situations on various levels and doing so with all kinds of makes and models of vehicles, stock from the factory and customized with aftermarket parts. This is what separates an expert, such as Carrol Shelby, warning someone to slow down from a lay person keyboard cowboy that might have some general common sense.

What Gillenator said is correct but there are other factors to consider such as timing. If you wake up the day after surgery and you have tiny whiteheads then it is a very very mild infection but one that can indeed get worse. If the recipient area just looks outright angry at any time in the first week then it is time to talk to your doctor but if you had one or two days of follow up visits with hair washes then they would have caught it and put you on topical or oral anti-biotics. If you're talking a few weeks or months post-op then one to four or five pimples at one time is OK as it indicates new growth and some hairs are getting trapped. Redness is normal but angry, obvious redness that stands out from the surrounding areas that are already red is a bad sign. Infection is something not discussed much on the forums nor in consultations. If you have not had surgery yet be sure to question your doctor about this issue, what experience do they have with infection and what they've done to deal with it.

The moniker "expert" has varying levels of legitimacy in the context of the question asked.There are people that have spent time reading so they may be "paper" experts with no practical experience. This in effect makes them experts on nothing more than the experience of others. There are people that have had procedures so, in some cases, they may be considered by some to be surgical experts but this can only go as far as their own experience. Rarely have the two melded into one. Being an expert is more than the sum of the two parts mentioned. It involves seeing multiple angles of an issue and using logic combined with experience as opposed to emotion and hearsay to convey legitimate information.

Thanks, guys. I need to clarify that currently I am independent but it does not mean I won't work with a doctor/clinic in the future. I'm open to the prospect but if I do, it will be on a different level than what I have done in the past. Once my site is relaunched it will be more clear what I'm doing.

Hi everyone, Over the past several months I've gotten many emails inquiring as to my whereabouts and what I'm up to. Some of you have noticed that I've not been posting in an official capacity for the Rahal clinic for some time now and this is because these duties were given over to another team member while I worked on a project behind the scenes. Now, however, I am no longer associated with Dr. Rahal or the Rahal Hair Transplant clinic. I've got ideas and plans that require I be independent and my departure has nothing to do with the quality of the work of Dr. Rahal. What I learned during my short tenure has been very valuable indeed and I'm grateful for the opportunity that was given to me. I still think he's a fantastic HT surgeon and I wish him and his team well. My website remodel will be complete soon and, with luck, it will be unique and very useful for those looking for transparent and honest information. Thank you, Joe

Hi Wazaam, I do not wish to take away from the thread so I'll keep this short. 1.) We concluded our relationship very recently. 2.) I have ideas and plans that, to implement, require that I be independent for reasons I'll discuss at a later time. However, my departure has nothing to do with the quality of Dr. Rahal's work and I still think he's a damned fine HT surgeon. While my tenure with Dr. Rahal was short, I learned a lot for which I am grateful. 3.) I've got some ideas but I'm not prepared to discuss them at this time. My website is going through a major overhaul and once it is ready in two to four weeks I'll be able to give more details. If the site pans out the way I hope, I think you'll find it very useful:)

I didn't say this so I'm not sure why you are bringing it up to me. Actually, no it doesn't mean he didn't have a hairline and yes, he did have a hairline... My guess is that 5400 grafts were placed throughout the top with the hairline lowered slightly. This would be confirmed by what I see as finer single hairs in the current result photo with larger grafts a couple of centimeters behind for bulk and/or coverage. Keep in mind, 5400 grafts on this scalp is an average of 1080 grafts per NW level. It's a lot, but it's not a lot, and if this hair in the photo above is now completely gone you better believe it would make a difference to the final result. Here are the facts: 1.) Patient was a NW5 with thinned native hair in the recipient zones. 2.) Patient received 5400 grafts which equates to 1080 grafts per NW level. 3.) The patient stopped taking hair loss medication after one year because he "wasn't told" to continue taking it with "it" I assume to be Rogaine. 4.) The patient has said that since the surgery he's lost a lot more hair, both native AND he says maybe transplanted. This could indicate a donor hair sensitivity to DHT or even a post-surgical condition such as lichen planopilaris (look it up). We don't know because we can't SEE past his hairline which is the entire point. 5.) Five years after his surgery he's shared one before photo taken, I assume, in his home as shown above and three post-op photos showing his hairline. 6.) The patient is understandably very upset. 7.) The patient has reached out to the clinic and they have offered at least some free work, five years after surgery, and with potentially no more evidence than we have. What we have is a very inconclusive situation where no one here knows a damned thing about why this patient has the result he has and if it is even a bad result "that sucks" to begin with or if it is something that deteriorated over the past five years. What we do know is that his hair was better at one point because he said he lost his native hair. How much better, we don't know, and I think that the patient should do himself and the clinic a favor and post up photos of all angles so that we all have a clear picture of what he's dealing with. It may be bad, it may be just ok. I'm not defending the work here. I'm defending fairness to both parties. And for those that have asked in this thread (Questionmark) and others, I have no benefit to discussing this beyond trying to get people to see reason as I no longer have a professional relationship with Dr. Rahal or the Rahal Hair Transplant clinic. I'm a free agent... with a plan.

Ready4hair, Do you think it is fair, or even logical, to judge the result of a NW5 patient with 5400 grafts and post-surgical hair loss, five years later, on the hairline alone? Conversely,do you think it is fair for a clinic to show the front, top and back of a NW7 patient before surgery and then only show the front of the result?

Why are we not seeing photos of the top of the scalp? I think that to call this a failed result with only three poorly shot hairline photos is hypocritical. If this were a clinic showing their latest result on a NW5 patient with an overhead before photo and only hairline after photos there would be pitchforks in the streets. You guys would be screaming for overhead photos and crown photos. I'm not saying the patient shouldn't be upset, I'm saying we don't know the whole picture so any judgments on our part is premature. 5400 grafts is a lot of hair for a hairline but he didn't have them put in the hairline. He had them placed across the top of his scalp and 5400 grafts is only an average of 1100 grafts per NW level as the poster stated he was a NW5 pre-surgery. Spread out, it isn't that much hair especially if the poster is going to brush his hair vertically as shown in the photos. I can barely do that myself and I've had twice as much hair transplanted as he has. Furthermore, show me a clinic that offers anything positive, much less free work, for a patient that shows up out of nowhere after five years and is not on hair loss medication and I'll show you a blue moon. Most clinics would demand a detailed visual representation of not only the current result but the "peak" of the result one to two years post-op. Let's see a proper comparison in photos and then our opinions can be valid. I'm not defending the work because I don't have all the visual facts, I'm simply defending diligence and fairness.