ArochaHair

Thank you for your comments and questions. When Dr. Arocha assessed this patient's loss he noted that he was a partial diffuse thinner but he could only see this after close examination. Dr. Arocha was able to place grafts in between the patient's existing hairs without causing damage. This is one of Dr. Arocha's specialties and this allowed the patient to have a reinforcement of his existing hair. We do have some placement photos and we have one photo showing the crown before placement, but wet, so you can better see the target recipient zone. Roughly 2/3 of the grafts were placed into the frontal hairline and distributed into the existing hair. Dr. Arocha slightly lowered the existing hairline and added density to what was already there. Here you can see the general area where Dr. Arocha felt the crown needed density. You can see the outlines made with his marker. If you have any further questions do not hesitate to ask.

This patient originally came to see us six years ago when he was concerned about his receding hairline and the small area of his crown that was experiencing additional loss. He felt that his otherwise youthful looks, especially for being in his mid-thirties at the time, were being compromised by these developments. Dr. Arocha and the team moved 3010 grafts via follicular unit strip surgery (FUSS) in one procedure and placed the grafts amongst his existing hair without shaving. The patient has continued on finasteride since the surgery.

Taking a second strip, outside of the previous strip, is considered to be unnecessary and even counter productive. There are cases of repair where this is necessary but with the increased emphasis on procedures being undetectable taking multiple strips from various locations contradicts this philosophy and makes undetectability more difficult.

The steps you should take are the ones that your clinic gives you post surgery. The number of surgeries do in fact affect the risk of a visible scar and the doctor or doctors will have to modify their approach with each subsequent surgery. They can take a more narrow strip, and longer, to avoid the consequences of an ever tightening scalp but eventually you get to the point where a doctor has to say "no more" or else a wide scar is unavoidable. #4 guard results and even #3 guard results are very possible and are quite common (assuming a quality clinic was used) but there should never be any guarantees given in this regard. No, donor scars do not generally become completely visible or even partially visible when the donor hair is wet, assuming the scar is of an acceptable width to begin with. If the donor hair is of low density then that may make the scar somewhat visible to you but probably not to others but if you combine a wide scar with low donor density then all bets are off.

I agree, a very good post but I disagree with the idea that finasteride does not actually stop hair loss for some patients because of the countless cases where thickening has occurred, sometimes even to the point of being a dramatic 180 degree turn around. It is wise to never assume this will be the case but sometimes it really is.

Here is a new video showing the same photos in a slideshow format for easier viewing.

Thank you for the suggestions. 911Fan, We will be working on such a video soon so stay tuned. Bitethebullet, We have dozens of individual cases on our Youtube channel. In fact, we have 63 videos and more are coming so feel free to browse those cases we've already shared:)

This 24 year old patient came to see Dr. Arocha about his receding hairline. He and Dr. Arocha discussed future preventative options and how to deal with his existing loss. Considering his family history and his hair style ambitions Dr. Arocha and the patient agreed that FUSS would be the preferred treatment moving forward. After scheduling the procedure and prepping for the big day the patient arrived and received 2500 grafts in one procedure. Results shown are at 13 months post-procedure.

This is something we see from time to time and it usually involves a few common scenarios. 1. The patient was seeking FUE but was told it was not possible for them. 2. The patient was told they have limited donor and they could not have more than a certain (low) number of grafts. 3. Previous scarring was worse than average and they were told it would impeded a successful repair. We've seen all of these cases and have agreed with some of the assessments but disagreed with others and wound up giving a very nice, and more importantly, a satisfying result for the patient. It is always worthwhile to get a second and even a third opinion. No one is correct 100% of the time but if you start getting a similar message from multiple reputable clinics then it may be time to heed the warnings and forget the idea of surgery altogether.

This female patient presented with traction alopecia affecting both temple point regions. When she initially arrived to visit Dr. Arocha to have her consultation she was limited to one hair style shown below. The hair style allowed her to cover the problem areas in the temple points which are revealed when the hair is lifted. The traction alopecia was due to pulling her hair back extremely tight for long periods of time over many years but she wished to return to a pull back hair style, albeit without as much tension. After discussions with Dr. Arocha and learning about her procedural options she opted for 2000 grafts via FUSS in one procedure. Dr. Arocha addressed both temple point regions and made some minor density improvements for the hairline as well. The results shown below represent eight months of recovery and growth.

We'd like to know what you think about the compilation presentation here but also compilations in general. Would you like to see more of these types of presentations or do you prefer singular results only?

I think it is important to note that the wonderful results achieved with the ARTAS in this particular case came about before the upgrade to the system. The most improvements being made to ARTAS only serve to make the experience better and the procedure more comprehensive with improved punch sizes as well as a wider field of extraction which helps to aid in the natural appearance of the donor once healed.

Thanks, Pete! Your comments are appreciated.

Learning to accept it and shave it is the safest route to take and it will also save you al to of money. However, if you do decide to try the surgical route you really should consider finasteride again and here is why. You used it for six to nine months without noticeable side effects so the already low odds of you having sexual side effects, much less effects that last a long time after you stop taking it, are pushed much further into the realm of "unlikely". The sudden acceleration of loss may also be caused by some other outside influence. Check your diet to make sure you haven't started ingesting something on a regular basis that may be causing the issue. Also, are you taking any other medications? Anti-depressants, particularly the SSRI variants, are known to have side effects that can included increased hair loss (telogen effluvium).

Matt and Pete said it well. Avoid surgery as much as you can and use medical options that are available first.

The issue also depends on how anchored the scabbing is and this has to do with how well the recipient zone was cleaned immediately after surgery. If the recipient was cleaned well and the scabs are separate from each other then ten days after surgery the scabs should be lifting by themselves unless you are being overly sensitive about touching them. If the area was not cleaned well and you have a confluence of scabbing over the recipient area then picking them off may cause damage as there is more scabbing to lift thus the potential for damage increases. Ultimately the post-op instructions should be followed to the letter, which is sounds like you did, and if they did not warn you of any issues then you should be fine.

Are you saying you have a double whorl pattern in your crown? This is rare but if you were bald in the crown or just very thin then a single whorl pattern could be recreated. If you are only mildly thinning then it would be destroying hair you have to build a new custom whorl pattern which is counterproductive to surgical hair restoration. In addition, the final result would likely look like a mess due to the varying angles and directions that would be fighting with your natural angles and directions. Are you on medication to stop your loss? If not then you may want to consider it to prevent further loss but to also maybe thicken what you have as that may be all you need to do.

You are not wrong in thinking that an HT can help you if your crown goes bald but why not prevent it from happening in the first place? It's like having a car and wondering if a good body shop will fix it if you decide to let go of the wheel and let it careen into a wall. Don't let go of the wheel and you won't have to find out. Once the car is fixed it is never as good as it was before an accident. Same thing goes for hair restoration. Once your crown goes no hair transplant can restore it completely and without medication it will most likely just get worse. Eliminate all possible options for keeping what you have first before you rely on surgery to give you back what you once had.

Hi 911fan, Yes, here is a before/after that we can share.

Hello Lorenzo, I already addressed those questions in point #4 in an earlier post in this thread. Thank you.

Shampoo, I think that strip is probably more comfortable during the procedure because the patient is in the harvesting position for a shorter period of time compared to FUE but the longer face down time of FUE is more than made up for by the quicker healing and less post operative discomfort. Pidda, your position on ARTAS makes sense if you had an unfavorable experience with it but this happens for patients that have strip and other forms of FUE as well. What you said about only having manual punches "in the right hands" is the entire point of this thread however in that ARTAS is a tool, just like a manual punch is a tool, and the tool is controlled by the doctor (or should be controlled by a doctor). The judgment of the doctor and how to use the tool determines (for the most part) the outcome of the procedure. For instance, the image you linked to is a clear indicator of poor judgement and then there is this image I posted of a recent manual punch extraction case: Manual extraction FUE immediate post-surgery. Compare the above manual extraction case to the ARTAS case I presented and the difference in judgement (and punch size of course) is clear. ARTAS extraction during surgery. The current state of ARTAS is not just about how the donor looks during surgery of course. The healed result is what matters as seen in this four month photo of the same patient: The message we wish to convey is that in any procedure the tools that are used are not determining the outcome of the surgery, the doctor and the staff are, because they are the ones controlling these tools. Just like two clinics that use manual can be different, two clinics that use ARTAS can be different as well. In fact, Arocha Hair Restoration is recognized by Restoration Robotics (the manufacturer of ARTAS) as an "ARTAS Center of Clinical Excellence" due to Dr. Arocha's experience in the field and how he applies this experience to using the robot as well as the feedback and suggestions he gives on it's use and how it can be improved. Only 10% of all clinics using ARTAS have this designation. We hope this clears up some of the confusion about ARTAS and dispels the myth that donor zones are automatically destroyed just because an ARTAS system was used. In our opinion, compared to many surgeries being performed today, some patients would be lucky to have an ARTAS system participating in their surgery.

Hello Bill, Yes, this has been our message. The ARTAS is a tool and it is best used by experienced hair restoration clinics. The impression I get from the responses in this thread is that the readers recognize that ARTAS is just that, a tool, and it is all dependent on the user. Pidda references an image that is a prime example of how not to use ARTAS but this image could have been an image of any extraction tool in use today. I did a search and there are some images online that are similar but were from manual hand held extraction techniques. The point is that no matter how good a tool may be it is only as good as the user and his or her judgement to use it. The problem that we see sometimes is when patients come in and repeat to us what they have heard from others. The ARTAS robot causes excessive scarring. The ARTAS robot uses punches that are too big. The ARTAS robot cannot cherry pick grafts. This thread intends to address these issues and others if anyone wants to present questions. 1. "The ARTAS robot causes excessive scarring." When the ARTAS robot first came out it was using punches that were too large. We don't dispute this and we don't think Restoration Robotics would dispute this either. The improvements have been coming just as they have been for every other form of FUE surgery. In the beginning of FUE before ARTAS there were only manual punches but the early debates discussed the benefits, if any, of going below 1mm in diameter. Then there were debates about the use of motorized punches and so on and so forth. The point is that they have all improved as has ARTAS. For instance, here are two photos of this same patient after the donor area healed. There is no massive scarring on this patient and it is very difficult to see any indicators that FUE was performed. When you compare the extractions of this latest ARTAS patient to the patient below which was done with handheld manual the difference is obvious. ARTAS extraction zone during surgery. Handheld manual extraction from a random clinic found online in Spain. 2. "The ARTAS robot uses punches that are too big." As I said, in the beginning this was the case and it was even using punches that Dr. Arocha felt were too big in general leading in to 2015 but this past 18 months has shown some real progress. The current standard is .9mm but .85mm is rolling out now and .8mm is expected by the end of the year. 3. "The ARTAS robot cannot cherry pick grafts." The ARTAS can now differentiate the number of hairs in each follicular unit and can be told which size groupings to target. This is the standard for how all top FUE clinics operate in that they will take the larger bundles and leave smaller one hair grafts behind to help prevent the moth-eaten effect. We can also set the parameters affecting extraction density. 4. "No top tier FUE clinics use ARTAS" Respectfully, we think this is inaccurate too. Some other well known clinics have tried ARTAS and decided to no longer continue with it's use but we feel they may have given up prematurely. We almost did as well and we are not new to the use of FUE. In fact. Dr. Arocha enjoys using manual hand held FUE tools but he decided to give ARTAS a second chance and he has learned that it is far better than it was when he first purchased the robot three years ago. One thing needs to be made clear. We do not feel that the robot is "better" than manual hand held extractions that we and other top FUE experts offer. ARTAS is a supplementary and where it excels above and beyond what any human can do is in it's consistency and lack of fatigue. Every top doc experiences this and it is unavoidable. Wear and tear can take it's toll on the human wrist and it is when fatigue sets in that mistakes can and do occur. With the improvements that have occurred (and are coming) to the robot the baseline standard of care and results are being elevated. In an age where unlicensed technicians are starting to dominate the hair restoration landscape we feel that the ARTAS, guided by an experienced hair restoration surgeon, is a safer option. ARTAS does not get tired. ARTAS does not come in hung over. ARTAS will never ever be a rookie that needs to be trained because every new ARTAS that comes off the assembly line has the cumulative knowledge and experience in it's learning algorithm (that is also pushed out to older machines as an update) from each and every one of the millions of extractions it has performed since the beginning which means it is getting "smarter" and more experienced every day.

Dr. Arocha feels that there is some negative information regarding the use of the ARTAS hair restoration robot. Some have said that the ARTAS system causes excessive donor scarring and damage due to unnecessarily large punches as well as having a reduced area of donor hair that the robot can harvest from which can contribute to the patient having a "moth eaten" donor zone. These are not concerns that are currently valid due to how the system operates and any tangible cosmetic downsides really come down to user judgement. The ARTAS system is unique in that it is continuously updated with new information to make it better. There is a steady stream of system updates that include, among other things, the control algorithm, the punch sizes and the dexterity of the robotic arm itself. These improvements are obvious and dramatic even when compared to what was being done only two short years ago. Dr. Arocha feels that these advancements to the ARTAS system warrant a second look. The case below is one that was performed six months ago where approximately 1800 grafts were harvested. The photos were taken during surgery so there is no post-operative power washing to clean the donor area. The ARTAS system is not perfect and Dr. Arocha feels that if one is to use the ARTAS in their practice the clinic should be in a position to take over with manual extraction if necessary but in general the benefits of the ARTAS system in it's current iteration are clear. When compared to any clinic using manual extraction it would be extremely difficult for even a trained eye to confidently say which extraction technique was used in these photos, manual punch extraction or extraction using the ARTAS robotic system.

Surgeons also look at how many hairs per follicular unit you have. How many doubles do you have? Triples, etc. If you are considering FUSS they'll also test your donor laxity to estimate how wide of a strip can be removed. If your donor area is thinning then most likely a hair transplant is out of the question because contrary what you might hear in a clinic there is no reliable way to determine which hairs will fall out and which will not. At any given time we have ten to fifteen percent of our hair in telogen and when a doctor looks at your scalp, even with a densimeter, they can't really know which hairs are terminal and which are miniaturizing because those that are miniaturizing might actually be coming back into anagen from the telogen state. The same is true for the opposite as well. You should visit a dermatologist and have them give you an assessment about your hair, not about a hair transplant. If they determine your donor hair is in a telogen effluvium of sorts then you'll need to isolate the reason why, if possible, before you consider any surgical options.

I don't think you should get a hair transplant but if you do, you'll need at least 2500 grafts to establish a good density. Anything less will have you back in the chair a year later to get the density you hoped for with the first procedure.