Dr. Paul Shapiro

Dr. Paul Shapiro, FUE Transplant, 1049 Grafts: Goal to bring down Frontal Temporal Angles. This 28 year old Norwood type II male was bothered by the recession of his frontal-temporal angles. He did have some thinning throughout the front 2/3 of his scalp which is noticeable with his hair wet, but under most conditions this thinning did not bother him. He chose to do a FUE hair transplant just to bring down his frontal temporal angles. We chose a conservative hair line because of his age and potential for future hair loss. We transplanted a total of 1049 FU’s. He recently came if for his 7 month follow up visit and is very happy with his results.

Dr. Paul Shapiro—3448 FU grafts, 37 year old, Class V-VI—14 months post op This 37 year old male has dark, coarse hair. His donor density was below average at 73 FU/sq.cm . Our goal was to get as much donor as possible. He had average laxity and a 1.5 cm wide by 31.5 cm long strip was removed. A Trichophytic closure was used. This yielded 3448 FU grafts and I covered an area of 110 cm.sq. to yield an average density of 31 FU/sq.cm The hair count is as follows: total yield 3448 FU/6316 hairs 992—1 hair FU 2070-2 hair FU 360—3 hair FU 26---4 hair FU The post op photos are done with the hair slightly damp because he has such thick hair it needed to be wet in order to comb it.

This 36 Year Old Male, Norwood type V came in for his one year follow up visit. I have posted his progress at 6 months: http://www.hairrestorationnetwork.com/eve/showthread.php?p=2066112&mode=threaded#post2066112 He is a good example of how there is usually more hair growth from 6 months to 1 year and one has to wait at least 1 year to acess the results of a hair tranplant surgery. He had a 4,000 FU graft surgery and more detalis can be found in his previous post. Below are his on year photos.

This 49 year old Pt had a Norwood 3 balding pattern with significant temporal recession but a strong frontal forelock. 2694 FU grafts were used to transplant the area. The frontal forelock was not transplanted but the central core area behind the forelock was transplanted. The patient had a tight donor and a low donor density of 70 FU/sq.cm. This limited the amount of donor I could remove. The area was transplanted at an average of 35 FU/sq. Since the patient has coarse curly hair this density gives a good cosmetic result. These results are at 6 months and we expect to see more density in one year. The distribution of grafts are: One hair FU-749, Two hair FU-1419, Three Hair FU-494. Four Hair FU-31.

This patient had a previous transplant at another clinic prior to visiting SMG. He was happy with his pattern but wanted more density in the frontal 1/2 of his scalp. I was limited in the amount of donor I could remove because he has poor donor density, a tight scalp, and had some scar stretch from his first transplant. I ended up getting 2087 grafts. He is two years out from surgery and is happy with his the density in the frontal ?? of his scalp. His graft count is as follows: 1 Hair FU - 669 2 Hair FU - 1109 3 Hair FU - 246 4 Hair FU ??“ 63 Total FU ??“ 2087 Total Hairs ??“ 3877

This 30 year old male came in for an 8 month follow up appointment. 2055 Follicular Units were used to recreate his hairline and reinforce his temporal angles. Since we were not going through much existing hair he did not need to have a hair cut for the surgery. He is very happy with his results.

Subtle Temporal Angle Change: This 55 year old man was bothered by a slight recession in his temporal angle. He was completely happy with the rest of his hairline. After discussion we decided to do a small case of about 300 FU's in each temporal angle. For the total surgery we used 626 FU's. He came in for his one year follow up visit and is very happy with the results. This is an example of how sometimes we only need to use a small amount of graphs to achieve the goals for the patient. DAY OF SURGERY/ONE YEAR POST OP COMPARISON PRE-OP/DAY OF SURGERY/ONE YEAR POST OP COMPARISON

I have gotten some comments that there is not much of a change in this transplant. The patient's goal was to lower his hairline by about 1 centimeter and for it to be a subtle change so that no one knew he had a hair transplant. When doing a transplant like this one it may seem like there is no change but as you can see in the following photographs the hairline was lowered. I have drawn in Red how far down we lowered the hairline. I also placed hair about 2 centimeters behind the hairline to give good density. When going into existing hair the change is not as significant as if one is going into a bald area. This patient is very happy with his results. THE RED LINE IS HOW MUCH WE LOWERED THE HAIRLINE PRE-OP/POST OP COMPARISON CLOSE UP VIEWS TO SEE THAT THE HAIRLINE WAS LOWERED Dr. Paul

This patient came in for his 6 month follow up appointment. He was a candidate for dense packing and I planted at densities up to 60 FU/sq.cm. He is a 38 year old male who has hair loss in the Norwood type II pattern. Most of the males in his family do not progress to more than a Norwood type IV but he does have an uncle who has Norwood type V hair loss. His donor density is average and he has very minimal crown loss. In a patient like this I feel comfortable dense packing the hairline. If he was in his 20s or had a family history with more significant hair loss I may have chosen to keep the densities in the 30 to 40FU/sq.cm. range. His hair count is as follows: 1 Hair FU 548 2 Hair FU 1061 3 Hair Fu 495 4 Hair FU 60 Total FU 2164 Total Hairs 4395 I can measure the exact density of my incisions by taking a close up photo in a one cm/sq view and then counting the incisions.

Here are 8 month post op photos on a Norwood Type 6 patient. I originally posted his day of surgery post op photos on the following photo album: http://hair-restoration-info.c...5103422&f=3521087683 This patient is 52 years old and wanted to cover as much of the bald area as possible. I covered the front ?? and most of the crown. The area covered is about 150 sqcm and on average his density is 30-35 FU/sq.cm. The density could have been higher if we decided not to cover the crown. I do expect to see some more growth over the next four months. His graft count is as follows: 1 Hair FU - 983 Hairs ??“ 983 2 Hair FU ??“ 2703 Hairs ??“ 5406 3 Hair FU - 856 Hairs ??“ 2568 4 Hair FU ??“ 102 Hairs - 408 Total FU - 4644 Total Hairs ??“ 9365 The total length of the strip was 26.5 cm long. At its widest the strip was 2cm wide in the middle and at the temples the strip was 1.5cm wide. The strip dimensions was as follows: 10.5 cm long of 2.0 cm wide strip 9.5 cm long of 1.8 cm wide strip 7.5 cm long of 1.5 cm wide strip

Grub12 There are many factors that influence graft survival. How the grafts are cut, how long they are out of the scalp, the density that they are planted, how carefully they are handled when planting into the scalp, and preventing dehydration are all important factors in graft survival. To scientifically study graft survival is very difficult. One needs to transplant hair into totally bald scalp in areas of scalp that can be accurately measured and then re-examined over time. In order to do this we have to tattoo one cm sq boxes on the scalp to accurately measure graft survival. There are not many studies on graft survival because not many patients want areas of their scalp tattooed. To complicate matters further, remember that about 10%-15% of one's hair is in the resting stage of growth and is not visible. So if I plant 10 hairs into a one sq.cm. area that has 10 existing hair, it is impossible in one year to tell what hair is transplanted hair and what hair is already existing hair. And the number of existing hairs can vary from 8 to 12 hairs in that one cm sq area because the percentage of hairs in the resting and growing stage do not stay consistent over time. So a study of hair survival is very difficult. The studies of hair survival in the Hair Transplant Literature shows anywhere from 90 to over 100% survival. But I would say on average the survival rate is about 95%. These studies are done under very controlled situations. They are done in one sq.cm boxes with densities anywhere from 30 to 60 FU/sq.cm. They are done as soon as the donor hairs are cut, and the best planters or doctors are planting the follicles. This is not the situation in real life. Taking these survival studies into consideration I do not think we can say we get 100% graft survival. I would guess that 95% graft survival is what most good clinics get. To complicate matters, studies show that graft survival decreases the longer the grafts are out of the body. The most commonly cited study shows that after 4 hours out of the body, the graft survival decreases to 95%, after 6 hours graft survival decreases to 90%, and then graft survival continues to decrease by 2% for every additional hour they are out of the body. If a case is larger than 2,000 FU it is very difficult to have all the planting done within four hours of the strip being excised. And as the cases get large in the 3,000, 4,000, and 5,000 range the cases even go longer than 6 hours. Studies also show that the type of medium the grafts are kept in do not greatly affect the outcome. Taking all this into consideration I agree with Bill in saying that graft yield is between 90% and 95%. If one looks at the studies done and just uses ones common sense one can see that 100% survival is almost impossible and the we should be happy with 90- 95% graft survival. I hope this is helpful Dr. Paul Shapiro

M1A1 This patient's donor strip was taken out in multiple sections. For the middle section I took out a 19.5 cm long by 1.6 cm wide strip. On the sides I decreased the width of the strip to 1.4 cm and took out two small strips totaling 9.5 cm long. I did not take a photo of this patient's donor density but by doing the math I took out a total of 44.5 sq.cm of donor and dividing that into 4,000 FU he donor density was 89 FU/sq.cm which is a little above average. I would say that on average I planted at a density of 30 FU/sqcm. This patient did not indicate that he wanted a second procedure. He still has 6 months of growth left and he is very happy with his coverage even at 6 months. He went from looking very bald to having a good frame of hair. For many patients this meets their expectations. But for other patients they would like more density or to have more crown coverage. Of course since he is only 34 years old and has the potential to become a Norwood Type VI we would have to be very judicious where we plant the graphs if he wants a second session. Dr. Paul

When I read this tread I think that there may be confusion as to what constitutes insurance fraud and what constitutes prescribing a medication off label. Prior to becoming a hair transplant surgeon I had vast experience in medical administration and had to be very conscious that my employees never engaged in insurance fraud. I worked for Glens Falls Hospital as a Medical Director of their Rural Health Clinics, and then as Associate Medical Director of the New York University Student Health Center, and also as a Medical Director of a Home Health Agency. When a drug gets approved by the FDA, the drug company needs to study the drug and prove that it is efficacious for the treatment proposed. Then it gets approved by the FDA for only the treatments that the drug company proved it was effective for. Prescribing that drug for any other reason is considered prescribing off label, but not fraud. A good example of this practice is a drug called Neurontin (Gabapentin). It is a drug that has been approved by the FDA to treat post herpetic neuropathy (the pain one gets after having shingles). But it is common in pain management to prescribe it for patients with chronic pain such as sciatic back pain. That is prescribing the drug off label, but it is not illegal. If I prescribe Finasteride 5mg at a does of ?? pill daily for hair loss and document in my note that I am prescribing it for hair loss with the instructions to split the pill into fourths, I am not doing anything fraudulent or illegal. I am writing an off label prescription. When the insurance company sees the Finasteride is prescribed that way it can then chose whether or not to cover it. If I prescribed it at the dose for benign prostatic hypertrophy which is 5 mg a day and some how indicate that I am prescribing it for the prostate when the patient does not have benign prostatic hypertrophy, then that can be considered insurance fraud. Also it would send a message on the patient's medical record that they have a prostate problem which isn't correct and could cause problems down the road since it seems like they have a pre-existing condition. Logically it makes sense that splitting the 5mg Finasteride into fourths would be as effective as taking the drug as Propecia. But since this has not actually been studied clinically I usually advise patients who are taking the medication for the first time to take it as Propecia at least for the first year. Then if it does not work there is no question as to whether the cutting of the pill in any way affected the outcome. The FDA just recently put out a good article of why tablet splitting can be risky: http://www.fda.gov/ForConsumer...pdates/ucm171492.htm Also, if there is a female in the house hold who is trying to get pregnant; one has to be especially careful that she is not exposed to the powder from cutting the pill. Merk has a good rebate plan for patients who are taking Propecia for the first time. This rebate program helps reduce the cost of the Propecia for the first year and I find it is a good incentive for first time users to use the brand name Propecia. I do agree with Dr. Reese that if I prescribed the Finasteride at the 5mg dose and did not document that I am instructing the patient to cut the pill into fourths and that the prescription is for the treatment of hair loss that could be considered insurance fraud. But with the correct documentation and writing on the prescription clearly that I am instructing the patient to cut the pill into fourths and take one fourth pill a day I do not believe I am doing anything illegal or fraudulent. I hope this is helpful Dr. Paul Shapiro

CalJudoka Both Dr. Reed and Dr..Hasson and Dr. Wong are excellent surgeons. Another suggestion is for you to request to speak to actual patients that have had surgeries in the clinics you are considering for your surgery. There is a good possibility there are patients in your area that may be amenable to you visiting them so you can see what the results look like in person. I did write a thread on why sometimes we seem to get as good results using less grafts in some cases. It might be beneficial for you to read this thread. http://hair-restoration-info.c...66060861/m/615103223 I hope this is helpful. Dr. Paul

This 34 year old male came in for his 6 month follow up visit today. He is very happy with his work. He is a Norwood type IV ??“ V and the males in his family have significant balding. He has significant balding in his crown but has not been on propecia. He did not want to go on propecia at the time of surgery. As you can see he looks like he has lost some more crown hair over the past 6 month so we started him on propecia today. In a case like his there is always the decision to make of if we should cover more area and get less density or cover less area and get more density. Since he has the potential of becoming a Norwood type VI we decided to cover a larger area. I covered 130-140 sq.cm. of scalp with 4,000 FU. I went back to the top of the crown but did not do any crown work. This resulted in a good coverage of hair with a natural look in 6 months. I do expect to see some more growth and greater density at his one year follow up visit. As I said he is very happy with the transplant already and he feels that we have accomplished his goals.

John Sorry but I did not ask him what size clipper he used for his hair cut. But it looks like a number 3. As for your redness. The healing process of a scar is complex and can take up to one year to completely heal. Most patients the redness is gone by 6 months. But I have seen patients in which it takes up to a year for the redness to go away. And in some cases even longer. It is easy to say be patient, but that is the best advice I can give you. Hopefully at one year your scar will be less noticeable. Dr. Paul

This 33 year old male came in for his 6 month pos op exam. The area of balding I covered is about 100 sq.cm. I was hoping to get 3,500 to 4,000 grafts. Unfortunately his donor skin was tight and his donor density was about 75 FU/sqcm which is below average. I first took out a donor strip that was 1.6 cm wide but the closure was tight and I had to decrease the width of his donor strip to 1.4 cm wide. His donor did yield 3118 grafts and fortunately he had a good percentage of 3 and 4 hair grafts to place in and behind the central core area. At 6 months he is looking good and very happy with his results, but I expect to see more growth over the next 6 months. Hopefully he will come in for a one year follow up and I can post more photos. His graft and hair breakdown is as follows: 1's ??“ 466 2's ??“ 1871 3's - 677 4's - 104 Total grafts 3118/Total hairs 6655

M$M Thank you for the positive comments. In this case I did cut the hair short in order to be able to go between the hairs and avoid transection. That is one of the advantages of cutting the hair short. Dr. Paul

The following quote by my brother Dr. Ron Shapiro eloquently summarizes what we are doing when we perform a hair transplant surgery: 'In hair restoration surgery we are trying to redistribute a limited amount of donor hair, with minimal waste and maximum survival, to a potentially expanding bald or thinning recipient area. We want to accomplish this redistribution in a manner that insures the patient will be satisfied with the results now and in the future. Patient satisfaction is dependent on meeting his/her expectations of naturalness, density, and amount of work needed.' The guidelines I mentioned in my post on dense packing take these basic principles in mind. ( http://hair-restoration-info.c...21087683&m=929107493) At what densities we get minimal waste with maximum survival is a judgment call that we need to make on an individual basis with each patient. The guidelines I set in my post are just guidelines. I think they represent common sense. I chose the age of 30 because I think it is very difficult to predict future hair loss when a patient is in their 20's. I feel more comfortable predicting future hair loss in patients in their 30's but even then it can be difficult. There are times that going outside of these guidelines may be appropriate as long as the risk and benefits are discussed in detail with the patient. Sometimes to get the high graft count needed in large cases we go outside the textbook 'safe' donor area. And sometimes in order to dense pack we use up donor in the front half knowing that there may not be enough donor to plant at similar densities in the temporal humps or top of the crown if the patient progresses to a Norwood type 6 or 7. I have had patients who say they are comfortable with this risk because they would rather look their best while they are young. It is judgment call to decide whether the benefits outweigh the risk. At the same time I do feel that younger patients sometimes do not completely understand the risk they are taking in using up a lot of donor and/or dense packing, especially if they are in there 20's. When I was in my 20's, fifty years old sounded like an old man to me. But I am going to be 55 my next birthday and that does not feel old to me at all. And a lot of my peers are single and in the dating scene and want to look the best they can. Unfortunately the divorce rate in the US is greater than 50% so a lot of guys will be single again even if they are married. As I showed in my post on dense packing that at SMG we can dense pack at densities up to 75FU/sqcm using the proper magnification and small custom cut blade. But this type of cases should only be done in the appropriate patients and I find that the majority of patients do not qualify for this type of sessions. Below is a quick review of the math involved in hair transplantation. When we are transplanting in the front ?? to the front 2/3 of the scalp we are covering an area that can measure from 80sq.cm. up to 150 sq.cm. If we were to plant at a density of 40Fu/sqcm we would need 3,200 to 6,000 FU grafts. If we were to plant at densities of 60 FU/sq.cm we would need 4,800 to 9,000 FU grafts. You can see that if we plant at the higher density of 60 FU/sqcm that does not leave much donor left for future hair loss. (This is the surface area needed to cover if one becomes a Norwood type 6 and the area can vary depending on how high ones temporal humps are) We need to carefully pick which patients we chose to dense pack. Even thought the procedure could look great today, we could paint ourselves into a corner so that 10 to 20 years down the road patient has an unnatural look and there is not enough donor left to make the transplant look natural. Unfortunately it takes that long to sometimes see the downside of what we do in a hair transplant. Dr. Paul Shapiro

This 43 year old male came in for a 6 month follow up exam. He was a good candidate for a 3,000 + Follicular Unit case, but unfortunately he had poor donor of 70 FU sq.cm and a tight scalp. I removed a strip that was 28.5 cm long. I first took out 7.5 cm of a 1.4 cm wide strip in the middle and then took out 21 cm at the decreased width of 1.2 cm wide. I focused on the front half of his scalp knowing that I would not get 3,000 FU. The total yield was 2528 FU. The hair count was as follows: 1 hair FU 754 Hairs 754 2 hair FU 1277 Hairs 2454 3 hair FU 448 Hairs 1344 4 hair FU 99 Hairs 396 Total Hair 2528 Total Hairs 4948 I did not take any side view photos before the surgery so there are no before and after side comparisons. I also did not take any immediate post op photos but he did let me shave the front ?? of his scalp. PRE-OP PHOTOS AREA TO TRANSPLANT PRE-OP/6 MONTH POST-OP COMPAIRSONS 6 MONTH POST OP CLOSE UP OF CENTRAL CORE 6 MONTH POST-OP HAIRLINE AND CLOSE UP DONOR SCAR 6 MONTHS POST-OP

Wounds heal in three stages: The fist stage is the inflammatory phase. In this phase the wound swells and the ingredients such as white blood cells, clotting factors, and fibrinogen for the adherence of the wound, prepare the wound for healing. This stage peaks at three to five days and the wound is very weak at this point. That is why it is very important to take it easy in the first week if one wants to avoid a wide scar. The second stage of healing is the collagen phase which starts at about one week post op. During this stage the collagen content increases and the wound strengthens. Sutures can be removed during this stage and we remove our sutures at 10 to 14 days. The second stage of healing last 2 to 4 weeks as the collagen content increases and the wound strengthens. The third stage of healing is called the maturation or remodeling phase and may continue for several years, with concomitant improvements in wound appearance. As new collagen replaces the old collagen the wound gets softer and the scar is less conspicuous. That is why we need to wait at least one year to determine how a scar is going to look. During the second stage of healing I tell patients they can go back to exercising but to use their common sense. If they do an activity that causes pain or a pulling sensation in the donor area then they have done too much. When weight lifting I recommend the patient goes down on the weights but increase his reps. It is important not to put too much stress on the upper neck and trapezius muscles during this stage. As for running it is ok to run at a pace that does not cause one to use the upper back muscles as accessory muscles to breathing. That pace differs for each patient and depends on ones fitness and also how one breathes when running. Sweat will not affect the surgery at the second stage of surgery because the outside of the wound should not have any scabbing and a skin barrier of epithelial tissue is already present. In summary it is very important to take it easy for the first week when the wound is in the first phase of healing. During the second phase of healing use your common sense. Try not to do activities that will put a lot of stress on the upper back and neck muscles. And if you do something and fell pulling in the donor area then you have overdone it and you are not ready for that activity. For example if you like to golf or play tennis, practice your swing and see how it fells. If you can feel some pulling in the area of the donor site then back off. During the third phase of surgery most exercise is fine. But I can still imagine someone who is into power lifting stretching the scar during this phase if they really push the weights. I hope this is helpful Dr. Paul

I am glad I posted these patients because there has been some good questions about what is dense packing and why are some clinic reporting planting in the hairline at a density of 70FU/sqcm. We should not lose sight of the basic principle of hair transplant surgery which is: We are using a limited donor supply to cover a potentially expanding area of balding scalp. I wrote a post called 'How Many Grafts Are Needed for a Hair Transplant Surgery' in which I reviewed this principal. The post can be found on the following link: http://hair-restoration-info.c...66060861&m=615103223 Another useful tool is the graft calculator in the HTN's multimedia center. If you go to the following link: http://www.hairtransplantnetwork.com/MM-center.asp it will bring you to the multimedia center. Scroll down the page to the box that is titled 'calculate # of grafts needed'. As you can see, if you want to plant hair at a density of 45 FU/sqcm. in the front ?? of the scalp (areas 1,2,3 &4) we would need to use 4,300 grafts. Studies suggest that the average lifetime donor for most patients is 4,000 to 8,000 grafts, with the average being 6,000 grafts. We need to take into consideration future hair loss when we plan a hair transplant surgery. That is why I only dense pack in patients who are at least 30 years of age, and I can confidently predict they won't advance to a Norwood type V or greater. Even though we can technically plant at densities greater then 40-50FU/sqcm, as I have shown in this post, I believe it is usually not the appropriate thing to do. I would say on average we plant at densities between 30 to 40 FU/sq.cm. We can plant at higher densities but the majority of our patients do not qualify for dense packing. At SMG we cut our blades and they usually measure from .6mm to 1mm. With proper magnification it is not difficult to make incisions at high densities from 50 to 70 FU/sq.cm. So in answer to one of the questions I do not believe there is a difference in whether we use cut to size blades or small needles. Another point I would like to make is that we are using 1,2,3, and 4 hair FU's in our transplants. It is important to mention hair count as well as graft count to accurately describe our surgeries. Planting 2 hair FU's at a density of 30 FU's'sqcm give us more total hairs then planting all one hair FU's at a density of 50 FU/sqcm. In the first case we end up with 60 hairs and in the second case we end up with 50 hairs. We have 10 more hairs at the lower density of 30FU/sq.cm. What most of us do in hair transplant surgery is to distribute the 1,2,3 and 4 hair FU's at different densities to give us the best results possible. Taking into account the principle of limited donor and selective distribution of different size hair follicles I would say that in on average we plant at densities between 30 and 40 FU/sqcm. We may plant the one hair FU's at a higher density and the four hair FU's at lower densities. That is why it is difficult to say exactly at what 'density' we are planting in a hair transplant surgery. The density varies depending on the size and caliber of the FU . In fact, I do think it is more common to plant one hair FU's at densities of 40-50 FU/sqcm. Thus, I would call dense packing any case in which we plant the 2 hair FU's at densities greater then 40FU/sqcm. I hope this is helpful Dr. Paul Shapiro